Provider Demographics
NPI:1295128098
Name:ROY, ANNA (NP-C)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ROY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:WIETOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3603
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2331 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4723
Practice Address - Country:US
Practice Address - Phone:773-772-7858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041359915363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL13543058OtherCAQH
IL209011573OtherSTATE LICENSE - ADVANCED PRACTICE NURSE
ILQXIPQ0000181327OtherAETNA BETTER HEALTH
A0513030OtherAANP - ADULT NURSE PRACTITIONER CERTIFICATION
A0513030OtherAANP - ADULT NURSE PRACTITIONER CERTIFICATION
ILF400206463Medicare PIN