Healthcare Provider Details

I. General information

NPI: 1477592947
Provider Name (Legal Business Name): JUDITH PRENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 OGDEN AVE STE 401
AURORA IL
60504-7208
US

IV. Provider business mailing address

5000 CHESHIRE PKWY N
PLYMOUTH MN
55446-4103
US

V. Phone/Fax

Practice location:
  • Phone: 630-585-7100
  • Fax:
Mailing address:
  • Phone: 888-510-0766
  • Fax: 763-268-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147000496
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: