Provider Demographics
NPI:1477150936
Name:PRESTON, DEBARA
Entity Type:Individual
Prefix:
First Name:DEBARA
Middle Name:
Last Name:PRESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 N BUCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2607
Mailing Address - Country:US
Mailing Address - Phone:847-460-8651
Mailing Address - Fax:
Practice Address - Street 1:1801 W TAYLOR ST STE 2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-996-1795
Practice Address - Fax:312-996-8218
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012224363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209012224OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION