=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750401303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL P PANKUS PNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 09/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 HARRISON ST
-----------------------------------------------------
City | BARRINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60010-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-381-7618
-----------------------------------------------------
Fax | 847-381-9198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3600 W FULLERTON AVENUE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-782-2800
-----------------------------------------------------
Fax | 773-782-5042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 209001706
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------