Provider Demographics
NPI:1295488666
Name:NUNN, DIMETRIUS
Entity type:Individual
Prefix:
First Name:DIMETRIUS
Middle Name:
Last Name:NUNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E 157TH PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11515 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-5611
Practice Address - Country:US
Practice Address - Phone:312-686-4877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty