Provider Demographics
NPI:1548097769
Name:BOUSHEH, IVONA
Entity type:Individual
Prefix:
First Name:IVONA
Middle Name:
Last Name:BOUSHEH
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 1:3050 PHEASANT CREEK DR APT 104
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3369
Mailing Address - Country:US
Mailing Address - Phone:773-954-4577
Mailing Address - Fax:
Practice Address - Street 1:3050 PHEASANT CREEK DR APT 104
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-3369
Practice Address - Country:US
Practice Address - Phone:773-954-4577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL209.030739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program