Provider Demographics
NPI:1104859818
Name:ORTWIG, DEYAN RENEE (NP)
Entity Type:Individual
Prefix:
First Name:DEYAN
Middle Name:RENEE
Last Name:ORTWIG
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 1:800 W CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2349
Mailing Address - Country:US
Mailing Address - Phone:847-618-5075
Mailing Address - Fax:847-618-3259
Practice Address - Street 1:800 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2349
Practice Address - Country:US
Practice Address - Phone:847-618-5075
Practice Address - Fax:847-618-3259
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209003571OtherSTATE LICENSE