Provider Demographics
NPI:1740012947
Name:EGHAREVBA, CHRISTY O
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:O
Last Name:EGHAREVBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SPARROW RD
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-2256
Mailing Address - Country:US
Mailing Address - Phone:708-743-2062
Mailing Address - Fax:
Practice Address - Street 1:9 SPARROW RD
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-2256
Practice Address - Country:US
Practice Address - Phone:708-743-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029811363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health