Provider Demographics
NPI:1013476324
Name:VEGA, ILSE GABRIELA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ILSE
Middle Name:GABRIELA
Last Name:VEGA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 W COVE CIR UNIT 3B
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-3161
Mailing Address - Country:US
Mailing Address - Phone:708-663-3493
Mailing Address - Fax:
Practice Address - Street 1:3303 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4036
Practice Address - Country:US
Practice Address - Phone:773-277-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily