Provider Demographics
NPI:1811401581
Name:BACHUS, MARVETTA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MARVETTA
Middle Name:
Last Name:BACHUS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19721 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1556
Mailing Address - Country:US
Mailing Address - Phone:773-979-2529
Mailing Address - Fax:
Practice Address - Street 1:19721 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411-1556
Practice Address - Country:US
Practice Address - Phone:773-979-2529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.4355332163WI0500X, 163WM1400X, 163WP0200X, 163WS0121X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WS0121XNursing Service ProvidersRegistered NursePlastic Surgery