Provider Demographics
NPI:1942623525
Name:WILKES, LARRY (FNP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WILKES
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 76TH ST STE 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-1640
Mailing Address - Country:US
Mailing Address - Phone:773-536-9922
Mailing Address - Fax:
Practice Address - Street 1:400 W 76TH ST STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-1640
Practice Address - Country:US
Practice Address - Phone:773-536-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-01
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041344165163W00000X
IL277000628363LP0808X, 363LF0000X, 363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health