Basic Information
Provider Information
NPI: 1003294620
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DOLAN
FirstName: THERESA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: APN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: NUGENT
OtherFirstName: THERESA
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 10408 GEORGIA LN
Address2:  
City: OAK LAWN
State: IL
PostalCode: 604534635
CountryCode: US
TelephoneNumber: 7089210777
FaxNumber:  
Practice Location
Address1: 5331 W 79TH ST
Address2:  
City: BURBANK
State: IL
PostalCode: 604593500
CountryCode: US
TelephoneNumber: 7084228101
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/14/2015
LastUpdateDate: 05/14/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X209.012794ILY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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