Provider Demographics
NPI:1023479417
Name:PATTON, MICIAH (FNP-C)
Entity type:Individual
Prefix:
First Name:MICIAH
Middle Name:
Last Name:PATTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4839 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2039
Mailing Address - Country:US
Mailing Address - Phone:773-735-2345
Mailing Address - Fax:773-735-4025
Practice Address - Street 1:4839 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2039
Practice Address - Country:US
Practice Address - Phone:773-735-2345
Practice Address - Fax:773-735-4025
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041378934163W00000X
IL209013960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse