Provider Demographics
NPI:1780912204
Name:NABONG, JENNIFER L (APN, FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:NABONG
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:WAAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11200 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11200 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8208
Practice Address - Country:US
Practice Address - Phone:815-464-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007794363L00000X
WI5804-33363LF0000X
IL209007794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner