Provider Demographics
NPI:1578764189
Name:PROVENZANO, SHEILA M (RN)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:M
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 BIESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3306
Mailing Address - Country:US
Mailing Address - Phone:847-690-1776
Mailing Address - Fax:847-690-1777
Practice Address - Street 1:555 BIESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3306
Practice Address - Country:US
Practice Address - Phone:847-690-1776
Practice Address - Fax:847-690-1777
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-320930163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse