Provider Demographics
NPI:1740914894
Name:REDA, DOMENICA (FNP-C)
Entity type:Individual
Prefix:
First Name:DOMENICA
Middle Name:
Last Name:REDA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E WACKER DR STE 1127
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2127
Practice Address - Country:US
Practice Address - Phone:312-429-5725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.444908163W00000X
IL209025545363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse