Provider Demographics
NPI:1780399055
Name:NYENKE, DOUGLAS (APRN, PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:NYENKE
Suffix:
Gender:
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10725 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3217
Mailing Address - Country:US
Mailing Address - Phone:312-857-4475
Mailing Address - Fax:773-666-7241
Practice Address - Street 1:10725 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643
Practice Address - Country:US
Practice Address - Phone:312-857-4475
Practice Address - Fax:773-666-7241
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026907363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659135416OtherBEVERLY PSYCHIATRIC SERVICES LLC