Provider Demographics
NPI:1770959397
Name:BRONSON, TAURA
Entity type:Individual
Prefix:
First Name:TAURA
Middle Name:
Last Name:BRONSON
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 1:20146 ARROYO AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1563
Mailing Address - Country:US
Mailing Address - Phone:773-851-2311
Mailing Address - Fax:
Practice Address - Street 1:20146 ARROYO AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411-1563
Practice Address - Country:US
Practice Address - Phone:773-851-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000000000Medicaid