Provider Demographics
NPI:1750857280
Name:TANKERSLEY, NAOMI
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:TANKERSLEY
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 1:2129 W 21ST PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4009
Mailing Address - Country:US
Mailing Address - Phone:574-220-1098
Mailing Address - Fax:
Practice Address - Street 1:2129 W 21ST PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4009
Practice Address - Country:US
Practice Address - Phone:574-220-1098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist