Provider Demographics
NPI:1356739452
Name:VICENCIO, JULIE (NP)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3538 HOPEWELL PL
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-5705
Mailing Address - Country:US
Mailing Address - Phone:630-962-6280
Mailing Address - Fax:
Practice Address - Street 1:525 E CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:630-962-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-26
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012352363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily