Provider Demographics
NPI:1942760962
Name:PROVAX, DESIREE MICHELLE (APN)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MICHELLE
Last Name:PROVAX
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5237 W WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3720
Mailing Address - Country:US
Mailing Address - Phone:773-547-3544
Mailing Address - Fax:
Practice Address - Street 1:5237 W WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3720
Practice Address - Country:US
Practice Address - Phone:773-547-3544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily