Provider Demographics
NPI:1356717102
Name:YANCY, BRANDIE RAQUEL (PA)
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:RAQUEL
Last Name:YANCY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15112 EVERS ST
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2621
Mailing Address - Country:US
Mailing Address - Phone:708-639-8770
Mailing Address - Fax:312-492-1222
Practice Address - Street 1:839 W 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-2699
Practice Address - Country:US
Practice Address - Phone:312-492-1220
Practice Address - Fax:312-492-1222
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005981363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical