Provider Demographics
NPI:1629231964
Name:OLDENBURG, NANCY LYNN
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:LYNN
Last Name:OLDENBURG
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 1:10331 KINGS CT
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8133
Mailing Address - Country:US
Mailing Address - Phone:815-543-7265
Mailing Address - Fax:
Practice Address - Street 1:2550 N ANNIE GLIDDEN RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1297
Practice Address - Country:US
Practice Address - Phone:815-758-6673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003441363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics