Provider Demographics
NPI:1558676221
Name:HALLIWELL, BOSEUNG (APN-CNP)
Entity Type:Individual
Prefix:
First Name:BOSEUNG
Middle Name:
Last Name:HALLIWELL
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-425-6400
Mailing Address - Fax:847-425-6408
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1700
Practice Address - Country:US
Practice Address - Phone:847-425-6400
Practice Address - Fax:847-425-6408
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012602363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
001783501OtherMEDICARE
P00907931OtherMEDICARE RAILROAD CARRIER
VT1018026Medicaid