| NPI | 1912445800 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TERRAH KOPPIE GAVRILOS Nurse Practitioner 2248-058-7113 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: IL 209015215) |
| Enumeration Date | 2017-02-10 |
| Last Update Date | 2017-02-10 |