Provider Demographics
NPI:1265476345
Name:PORTNOY, DAYNA NICOLE (NP)
Entity Type:Individual
Prefix:MISS
First Name:DAYNA
Middle Name:NICOLE
Last Name:PORTNOY
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 1:380 RIDGE AVE
Mailing Address - Street 2:14-2
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3357
Mailing Address - Country:US
Mailing Address - Phone:847-905-0654
Mailing Address - Fax:
Practice Address - Street 1:1200 CENTRAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2654
Practice Address - Country:US
Practice Address - Phone:847-256-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-265829163WG0000X
IL209-006098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00378000OtherMEDICARE RAILROAD
ILXXXXXXXXX-001Medicaid
ILQ74978Medicare UPIN
ILP00378000OtherMEDICARE RAILROAD
ILK34762Medicare ID - Type UnspecifiedLAKE-GROUP# 203191
ILK34761Medicare ID - Type UnspecifiedCOOK-GROUP# 450690
ILK49310Medicare PIN