Provider Demographics
NPI:1003361619
Name:JANICKI, TAMYRA MICHELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TAMYRA
Middle Name:MICHELLE
Last Name:JANICKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 BUTTERFIELD RD STE 206
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5602
Mailing Address - Country:US
Mailing Address - Phone:630-317-7690
Mailing Address - Fax:630-317-7894
Practice Address - Street 1:1315 BUTTERFIELD RD STE 206
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5602
Practice Address - Country:US
Practice Address - Phone:630-317-7690
Practice Address - Fax:630-317-7894
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014617363LF0000X
IL277000587363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily