Provider Demographics
NPI:1003299165
Name:PANAMBO, JULIET IBANEZ (AGPCNP)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:IBANEZ
Last Name:PANAMBO
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5258 S DREXEL AVE
Mailing Address - Street 2:1F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3752
Mailing Address - Country:US
Mailing Address - Phone:312-208-4962
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 745
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-0745
Practice Address - Country:US
Practice Address - Phone:630-400-1575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012519363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.012519OtherSTATE LICENSE APN