Provider Demographics
NPI:1750804167
Name:KREKLOW, YOLANTA
Entity type:Individual
Prefix:
First Name:YOLANTA
Middle Name:
Last Name:KREKLOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7226
Mailing Address - Country:US
Mailing Address - Phone:815-444-9999
Mailing Address - Fax:
Practice Address - Street 1:145 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7226
Practice Address - Country:US
Practice Address - Phone:815-444-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016064363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209016064Medicaid