Basic Information
| Provider Information | |||||||||
| NPI: | 1225386345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRIKSON | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | DEDIC | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 SOUTH 1ST AVENUE | ||||||||
| Address2: | |||||||||
| City: | MAYOOWD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 E SUPERIOR ST STE 4-420 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126950990 | ||||||||
| FaxNumber: | 3124724784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0200X | 041347688 | IL | N | Nursing Service Providers | Registered Nurse | Oncology | 363L00000X | 209009963 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 209.009963 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.