Provider Demographics
NPI:1053585398
Name:TKACZ, JOANNA (AGENT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:TKACZ
Suffix:
Gender:F
Credentials:AGENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 S MELVINA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2618
Mailing Address - Country:US
Mailing Address - Phone:773-581-1698
Mailing Address - Fax:
Practice Address - Street 1:5304 S MELVINA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2618
Practice Address - Country:US
Practice Address - Phone:773-581-1698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILACC/HEALTH--11/09/06171W00000X
ILACC/HEALTH171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL17OtherOTHER SERVICE PROVIDERS