Provider Demographics
NPI:1649637976
Name:ZEVALLOS, LIBIN MANUEL (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:LIBIN
Middle Name:MANUEL
Last Name:ZEVALLOS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LIBIN
Other - Middle Name:MANUEL
Other - Last Name:ZEVALLOS QUINONEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4952 W IRVING PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2640
Mailing Address - Country:US
Mailing Address - Phone:773-942-6141
Mailing Address - Fax:847-672-4799
Practice Address - Street 1:4952 W IRVING PARK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2640
Practice Address - Country:US
Practice Address - Phone:773-942-6141
Practice Address - Fax:847-672-4799
Is Sole Proprietor?:No
Enumeration Date:2016-01-17
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.473317163W00000X
IL238.000480246ZC0007X
IL209.022777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant