Provider Demographics
NPI:1801287685
Name:FATIMA, KANEEZ (SA-C)
Entity type:Individual
Prefix:
First Name:KANEEZ
Middle Name:
Last Name:FATIMA
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1807
Mailing Address - Country:US
Mailing Address - Phone:602-332-4905
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-823-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-14
Last Update Date:2015-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11-116246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant