Provider Demographics
NPI:1538744107
Name:YENGWIA, PETRA (NP)
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:YENGWIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PETRA
Other - Middle Name:
Other - Last Name:YENGWIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:861 N TAMARAC BLVD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:858-349-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021444363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209021444OtherLICENSE NUMBER