Provider Demographics
NPI:1053450494
Name:ZACHARIA, ANCY (NP)
Entity Type:Individual
Prefix:
First Name:ANCY
Middle Name:
Last Name:ZACHARIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N MAIN ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-614-4960
Mailing Address - Fax:630-682-3727
Practice Address - Street 1:1800 N MAIN ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-614-4960
Practice Address - Fax:630-682-3727
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041287164363LG0600X
IL209000424363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE8854OtherRR MEDICARE PTAN (GROUP)
IL363149833OtherTAX IDENTIFICATION NUMBER
IL041287164Medicaid
ILK03097OtherMEDICARE PTAN (INDIVIDUAL)
IL208015OtherMEDICARE GROUP NUMBER
ILP00068858OtherRR MEDICARE PTAN (INDIVIDUAL)
ILP00068858OtherRR MEDICARE PTAN (INDIVIDUAL)
IL$$$$$$$$$001Medicaid