Individual
TIFFANY R VANDIVIER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
946 N RACINE AVE, CHICAGO, IL 60642-4126
(330) 998-5862
Mailing address
946 N RACINE AVE, CHICAGO, IL 60642-4126
(330) 998-5862
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209027924
IL
Other
Enumeration date
08/09/2023
Last updated
08/09/2023
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