Individual
LARONE NUTALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
7138 S COLES AVE APT 2A, CHICAGO, IL 60649-2628
(708) 915-0517
Mailing address
PO BOX 490563, CHICAGO, IL 60649-0035
(708) 915-0517
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
095808
IL
Other
Enumeration date
04/19/2023
Last updated
04/19/2023
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