Provider Demographics
NPI:1265971204
Name:BASNILLO- SAN DIEGO, VENUS LIEZL (APN)
Entity type:Individual
Prefix:
First Name:VENUS LIEZL
Middle Name:
Last Name:BASNILLO- SAN DIEGO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 N BELL AVE
Mailing Address - Street 2:APT. 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5289
Mailing Address - Country:US
Mailing Address - Phone:773-600-1309
Mailing Address - Fax:
Practice Address - Street 1:1628 N BELL AVE
Practice Address - Street 2:APT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5289
Practice Address - Country:US
Practice Address - Phone:773-600-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015653363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health