Provider Demographics
NPI:1659449767
Name:CEBALLOS, DANIEL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 W HARRISON ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3788
Mailing Address - Country:US
Mailing Address - Phone:312-421-3219
Mailing Address - Fax:
Practice Address - Street 1:3600 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2319
Practice Address - Country:US
Practice Address - Phone:773-782-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003925363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health