Provider Demographics
NPI:1558036293
Name:PANGANIBAN, MA TERESA DATOON (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MA TERESA
Middle Name:DATOON
Last Name:PANGANIBAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 ASPEN LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-2139
Mailing Address - Country:US
Mailing Address - Phone:630-965-3354
Mailing Address - Fax:
Practice Address - Street 1:1920 ASPEN LN
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-2139
Practice Address - Country:US
Practice Address - Phone:630-965-3354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020448363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care