Provider Demographics
NPI:1669215141
Name:ICONIC NURSE NETWORK OUTREACH, INC
Entity type:Organization
Organization Name:ICONIC NURSE NETWORK OUTREACH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:LAKHILA
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CHW
Authorized Official - Phone:312-468-8604
Mailing Address - Street 1:730 N CHURCH ST # LL-3
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-6917
Mailing Address - Country:US
Mailing Address - Phone:312-931-7376
Mailing Address - Fax:
Practice Address - Street 1:730 N CHURCH ST # LL-3
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-6917
Practice Address - Country:US
Practice Address - Phone:312-931-7376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public HealthGroup - Multi-Specialty