Provider Demographics
NPI:1922410117
Name:TAFAZOLI, SHIVA (FNP)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:TAFAZOLI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:STE 402
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1624
Mailing Address - Country:US
Mailing Address - Phone:847-235-6130
Mailing Address - Fax:847-235-6135
Practice Address - Street 1:1954 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1016
Practice Address - Country:US
Practice Address - Phone:630-560-5439
Practice Address - Fax:630-701-1007
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041343828163W00000X
IL209011295363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse