Provider Demographics
NPI:1144984915
Name:IHEJIETO, DORIS CHIZOMA
Entity type:Individual
Prefix:
First Name:DORIS
Middle Name:CHIZOMA
Last Name:IHEJIETO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 W BERWYN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3460
Mailing Address - Country:US
Mailing Address - Phone:312-371-5995
Mailing Address - Fax:
Practice Address - Street 1:4259 S BERKELEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3030
Practice Address - Country:US
Practice Address - Phone:773-268-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023288363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily