Healthcare Provider Details

I. General information

NPI: 1386994051
Provider Name (Legal Business Name): HAILAN WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 RENAISSANCE DR SUITE 207
PARK RIDGE IL
60068-1330
US

IV. Provider business mailing address

1420 RENAISSANCE DR SUITE 207
PARK RIDGE IL
60068-1330
US

V. Phone/Fax

Practice location:
  • Phone: 184-729-6616
  • Fax: 184-729-6626
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.009761
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.009761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: