Organization
IGLOW AESTHETICS AND MED SP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SHAMMONA CLARK NP (OWNER)
(574) 298-3090
Entity
Organization
Contact information
Practice address
2600 S MICHIGAN AVE STE LLD, CHICAGO, IL 60616
(312) 866-4642
Mailing address
2600 S MICHIGAN AVE STE LLD, CHICAGO, IL 60616
(312) 866-4642
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
277001127
LICENSE
IL
Enumeration date
01/03/2023
Last updated
01/03/2023
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