Provider Demographics
NPI:1750842522
Name:CHICON, AIDA ALTAGRACIA
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:ALTAGRACIA
Last Name:CHICON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11719 BLACKBURN DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-1402
Mailing Address - Country:US
Mailing Address - Phone:708-289-3242
Mailing Address - Fax:
Practice Address - Street 1:4815 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2501
Practice Address - Country:US
Practice Address - Phone:708-499-2210
Practice Address - Fax:708-499-2250
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily