Provider Demographics
NPI:1356433940
Name:IANTORNO, ANDREA (APRN BC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:IANTORNO
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 LAKE COOK ROAD
Mailing Address - Street 2:SUITE M
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5234
Mailing Address - Country:US
Mailing Address - Phone:847-945-4550
Mailing Address - Fax:847-948-8103
Practice Address - Street 1:2750 S RIVER RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-4103
Practice Address - Country:US
Practice Address - Phone:847-470-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309001889163WP0000X
IL209004590363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WP0000XNursing Service ProvidersRegistered NursePain Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09912Medicare ID - Type Unspecified
ILK23083Medicare ID - Type Unspecified
P79291Medicare UPIN