Healthcare Provider Details

I. General information

NPI: 1891277646
Provider Name (Legal Business Name): AMBER MARIE VLADIKA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

2442 LAKEWOOD DR
DYER IN
46311-2128
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 708-420-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017978
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71009454A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: