Provider Demographics
NPI:1568903300
Name:BORUC, AGNIESZKA (NP)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:BORUC
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 1:1851 SILVER CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-300-3080
Mailing Address - Fax:
Practice Address - Street 1:18350 KEDZIE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2700
Practice Address - Country:US
Practice Address - Phone:708-365-1055
Practice Address - Fax:708-799-1249
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily