Provider Demographics
NPI:1376908301
Name:GREGG, DOUGLAS ROBERT (FNP-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ROBERT
Last Name:GREGG
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2334
Mailing Address - Country:US
Mailing Address - Phone:224-307-2333
Mailing Address - Fax:
Practice Address - Street 1:1315 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2334
Practice Address - Country:US
Practice Address - Phone:224-307-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.364931163W00000X
IL209.013635363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse