Healthcare Provider Details

I. General information

NPI: 1952811366
Provider Name (Legal Business Name): ANDRILYN NEDEDOG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 APPLETON LN
LAKE VILLA IL
60046-6405
US

IV. Provider business mailing address

308 APPLETON LN
LAKE VILLA IL
60046-6405
US

V. Phone/Fax

Practice location:
  • Phone: 224-330-7751
  • Fax:
Mailing address:
  • Phone: 224-330-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.016674
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.016674
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: