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General NPI Number Information
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NPI Number | 1356717102
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Entity Type | Individual
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Provider Name | BRANDIE RAQUEL YANCY PA
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Gender | Female
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Dates
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Enumeration Date | 08/17/2015
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Last Update Date | 01/15/2025
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Provider Practice Location Address
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Address Line | 839 W 79TH ST
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City | CHICAGO
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State | IL
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Zip | 60620-2699
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Country | US
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Telephone | 312-492-1220
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Fax | 312-492-1222
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Provider Business Mailing Address
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Address Line | 15112 EVERS ST
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City | DOLTON
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State | IL
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Zip | 60419-2621
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Country | US
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Telephone | 708-639-8770
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Fax | 312-492-1222
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085005981
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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