Healthcare Provider Details

I. General information

NPI: 1376908301
Provider Name (Legal Business Name): DOUGLAS ROBERT GREGG APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 LINCOLN ST
EVANSTON IL
60201-2334
US

IV. Provider business mailing address

1315 LINCOLN ST
EVANSTON IL
60201-2334
US

V. Phone/Fax

Practice location:
  • Phone: 773-370-0299
  • Fax:
Mailing address:
  • Phone: 847-868-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.364931
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.013635
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: