Healthcare Provider Details

I. General information

NPI: 1134969637
Provider Name (Legal Business Name): BROOKE WOLD DMS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17800 KEDZIE AVE
HAZEL CREST IL
60429-2029
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 708-213-4200
  • Fax: 708-213-0144
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010072
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: