Provider Demographics
NPI:1679038186
Name:FANDOHAN, DORIS (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:FANDOHAN
Suffix:
Gender:F
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 1:30 W MONROE ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2420
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:3046 127TH ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1827
Practice Address - Country:US
Practice Address - Phone:708-377-7920
Practice Address - Fax:708-930-0414
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008752A363LF0000X
IL209019405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71008752AOtherNURSE PRACTITIONER LICENSE NUMBER