Healthcare Provider Details

I. General information

NPI: 1689472789
Provider Name (Legal Business Name): ERIKA DETTLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10370 HALIGUS RD STE 201
HUNTLEY IL
60142-9582
US

IV. Provider business mailing address

10370 HALIGUS RD STE 201
HUNTLEY IL
60142-9582
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-2752
  • Fax: 815-455-2789
Mailing address:
  • Phone: 815-455-2752
  • Fax: 847-802-7401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: