Healthcare Provider Details

I. General information

NPI: 1669106894
Provider Name (Legal Business Name): RUTH ELAINE DEYOUNG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2681 ROUTE 394
CRETE IL
60417-4353
US

IV. Provider business mailing address

2681 ROUTE 394
CRETE IL
60417-4353
US

V. Phone/Fax

Practice location:
  • Phone: 708-672-6111
  • Fax: 708-414-2119
Mailing address:
  • Phone: 708-672-6111
  • Fax: 708-414-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041229390
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: