Healthcare Provider Details

I. General information

NPI: 1669228680
Provider Name (Legal Business Name): AYHESHA J. PRYOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 NORTH AVENUE
OAK PARK IL
60302
US

IV. Provider business mailing address

6551 NORTH AVENUE
OAK PARK IL
60302
US

V. Phone/Fax

Practice location:
  • Phone: 708-269-1533
  • Fax:
Mailing address:
  • Phone: 708-269-1533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.030223
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: