1295128098 NPI number — ANNA ROY NP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295128098 NPI number — ANNA ROY NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROY
Provider First Name:
ANNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIETOR
Provider Other First Name:
ANNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295128098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3603
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60522-3603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2331 W CHICAGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-4723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-772-7858
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  041359915 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13543058 . This is a "CAQH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 209011573 . This is a "STATE LICENSE - ADVANCED PRACTICE NURSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: QXIPQ0000181327 . This is a "AETNA BETTER HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: A0513030 . This is a "AANP - ADULT NURSE PRACTITIONER CERTIFICATION" identifier . This identifiers is of the category "OTHER".




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