Provider Demographics
NPI:1861490138
Name:FAGADORE, MARIAELENA J (CNP)
Entity Type:Individual
Prefix:
First Name:MARIAELENA
Middle Name:J
Last Name:FAGADORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4254 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4642
Mailing Address - Country:US
Mailing Address - Phone:773-582-5200
Mailing Address - Fax:773-582-2772
Practice Address - Street 1:4254 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4642
Practice Address - Country:US
Practice Address - Phone:773-582-5200
Practice Address - Fax:773-582-2772
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR45506163WP0200X
FL9244538363LP0200X
IL209-015320363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307963500Medicaid
NM92187315Medicaid