Provider Demographics
NPI:1932700911
Name:PORTILLO, LAURA IVETTE (APN-CNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:IVETTE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 GROSS POINT RD STE 1200
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1214
Mailing Address - Country:US
Mailing Address - Phone:847-945-7246
Mailing Address - Fax:847-733-5075
Practice Address - Street 1:9600 GROSS POINT RD STE 1200
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-945-7246
Practice Address - Fax:847-733-5075
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022746363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner