Provider Demographics
NPI:1659846301
Name:VIVANCO, JULIE L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:VIVANCO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:VIVANCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JACKSON
Mailing Address - Street 1:7118 35TH ST
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3216
Mailing Address - Country:US
Mailing Address - Phone:312-288-1113
Mailing Address - Fax:312-864-9009
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-288-1113
Practice Address - Fax:312-864-9009
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041256815163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management