{
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"FirstLineMailingAddress": "2644 N WAYNE AVE",
"SecondLineMailingAddress": "UNIT C",
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"MailingAddressStateName": "IL",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "312-505-0156",
"MailingAddressFaxNumber": "773-529-3911",
"FirstLinePracticeLocationAddress": "2644 N WAYNE AVE APT C",
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"EnumerationDate": "09/15/2016",
"LastUpdateDate": "12/28/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PETENZI",
"AuthorizedOfficialFirstName": "DENISE",
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"AuthorizedOfficialCredential": "DPM",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Podiatrist",
"LicenseNumber": "016005107",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}