Healthcare Provider Details

I. General information

NPI: 1528252061
Provider Name (Legal Business Name): CLEAUQUITA WILEY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date: 12/16/2021
Reactivation Date: 01/26/2022

III. Provider practice location address

2727 W 97TH ST
EVERGREEN PARK IL
60805-2733
US

IV. Provider business mailing address

2727 W 97TH ST
EVERGREEN PARK IL
60805-2733
US

V. Phone/Fax

Practice location:
  • Phone: 773-732-3770
  • Fax:
Mailing address:
  • Phone: 773-732-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.024630
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number041-353003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: