Provider Demographics
NPI:1578532198
Name:WILTSIE, JAN L (NP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:WILTSIE
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 1:820 S DAMEN AVE
Mailing Address - Street 2:JESSE BROWN VA, EMPLOYEE HEALTH
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3728
Mailing Address - Country:US
Mailing Address - Phone:312-569-7159
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:EMPLOYEE HEALTH
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-7159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WP2201X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care