Individual
TARA DEDIC HENRIKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APN
Contact information
Practice address
250 E SUPERIOR ST STE 4-420, CHICAGO, IL 60611-2914
(312) 695-0990
(312) 472-4784
Mailing address
2160 SOUTH 1ST AVENUE, MAYOOWD, IL 60153
(708) 216-9000
Taxonomy
Speciality
Code
Description
License number
State
163WX0200X
Oncology Registered Nurse
041347688
IL
363L00000X
Nurse Practitioner
209009963
IL
363LA2200X
Adult Health Nurse Practitioner
Primary
209.009963
IL
Other
Enumeration date
08/21/2012
Last updated
09/18/2019
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