MEDICARE: HOLLY M WENTLAND CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	209005315	IL

General Provider Information

NPI Number	:	1427136373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY M WENTLAND CNP

Provider Business Mailing Address
First Line	:	680 N LAKE SHORE DR STE 810
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-8700
Country	:	US
Telephone Number	:	312-926-8811
Fax Number	:	312-926-8855

Provider Business Practice Location Address
First Line	:	680 N LAKE SHORE DR STE 810
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-8700
Country	:	US
Telephone Number	:	312-926-8811
Fax Number	:	312-926-8855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	05/27/2020

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