Provider Demographics
NPI:1760030498
Name:JOSEPH, TANIYAMOL (NP)
Entity Type:Individual
Prefix:MISS
First Name:TANIYAMOL
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8995 KENNEDY DR APT 1F
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-5400
Mailing Address - Country:US
Mailing Address - Phone:224-616-0485
Mailing Address - Fax:
Practice Address - Street 1:2504 WASHINGTON ST STE 102
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4960
Practice Address - Country:US
Practice Address - Phone:847-623-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019253363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner