Provider Demographics
NPI:1124809074
Name:PANGANIBAN, ANNE JELIE D
Entity type:Individual
Prefix:
First Name:ANNE JELIE
Middle Name:D
Last Name:PANGANIBAN
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 1:2200 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-3209
Mailing Address - Country:US
Mailing Address - Phone:224-217-0557
Mailing Address - Fax:
Practice Address - Street 1:415 W GOLF RD STE 52
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3923
Practice Address - Country:US
Practice Address - Phone:847-258-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.015379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist