Provider Demographics
NPI:1790313674
Name:MANUYAG, JOLENE K
Entity Type:Individual
Prefix:
First Name:JOLENE K
Middle Name:
Last Name:MANUYAG
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 1:12 SALT CREEK LN STE 425
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-8603
Mailing Address - Country:US
Mailing Address - Phone:630-789-2260
Mailing Address - Fax:
Practice Address - Street 1:12 SALT CREEK LN STE 425
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-8603
Practice Address - Country:US
Practice Address - Phone:312-848-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily