Provider Demographics
NPI:1912260407
Name:RICHARDSON-BELGRAVE, TANYA MARIA (CNP)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:MARIA
Last Name:RICHARDSON-BELGRAVE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2901
Mailing Address - Country:US
Mailing Address - Phone:815-936-7371
Mailing Address - Fax:815-936-6971
Practice Address - Street 1:1701 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2670
Practice Address - Country:US
Practice Address - Phone:815-935-9394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily