Healthcare Provider Details

I. General information

NPI: 1114688918
Provider Name (Legal Business Name): AIDAN MARIE EX-WILLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 55TH ST
CHICAGO IL
60615-5512
US

IV. Provider business mailing address

1525 E 55TH ST
CHICAGO IL
60615-5512
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 773-388-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.009886
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: