MEDICARE: MR. DOUGLAS NYENKE APRN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209026907	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659135416	OTHER		BEVERLY PSYCHIATRIC SERVICES LLC

General Provider Information

NPI Number	:	1780399055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS NYENKE APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	10406 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2508
Country	:	US
Telephone Number	:	312-857-4475
Fax Number	:	773-666-7241

Provider Business Practice Location Address
First Line	:	10406 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2508
Country	:	US
Telephone Number	:	312-857-4475
Fax Number	:	773-666-7241

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2023
Last Update Date	:	09/02/2025

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