Provider Demographics
NPI:1164703310
Name:MEDALLE, GINA V (APN-BC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:V
Last Name:MEDALLE
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 N. MICHIGAN AVE. 10TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 N MICHIGAN AVE FL 10
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5517
Practice Address - Country:US
Practice Address - Phone:312-424-5113
Practice Address - Fax:312-424-6518
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008579363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health