Provider Demographics
NPI:1184194813
Name:VLADIKA, ABBY RUTH (APN)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:RUTH
Last Name:VLADIKA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-875-4531
Mailing Address - Fax:
Practice Address - Street 1:535 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2537
Practice Address - Country:US
Practice Address - Phone:815-875-4531
Practice Address - Fax:815-876-2118
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209018454Medicaid