Provider Demographics
NPI:1245858117
Name:HEADLEY, EMILY VICTORIA (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:VICTORIA
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 N WESTERN AVE STE 134
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1431 N WESTERN AVE STE 134
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-235-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant