Healthcare Provider Details

I. General information

NPI: 1265476345
Provider Name (Legal Business Name): DAYNA NICOLE PORTNOY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CENTRAL AVE SUITE 200
WILMETTE IL
60091-2654
US

IV. Provider business mailing address

380 RIDGE AVE 14-2
EVANSTON IL
60202-3357
US

V. Phone/Fax

Practice location:
  • Phone: 847-256-1705
  • Fax:
Mailing address:
  • Phone: 847-905-0654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-006098
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041-265829
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: