Provider Demographics
NPI:1588627558
Name:KNUCKEY, JANICE C (NP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:C
Last Name:KNUCKEY
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 1:675 N. ST. CLAIR
Mailing Address - Street 2:SUITE 19-100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3056
Mailing Address - Country:US
Mailing Address - Phone:312-695-4965
Mailing Address - Fax:
Practice Address - Street 1:675 N. ST. CLAIR
Practice Address - Street 2:SUITE 19-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3056
Practice Address - Country:US
Practice Address - Phone:312-695-4965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005156363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ22659Medicare UPIN