Provider Demographics
NPI:1831772912
Name:WLODEK, AMY CHRISTINE (APRN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:CHRISTINE
Last Name:WLODEK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 SALEM LAKE DR STE F3880
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:
Practice Address - Street 1:3880 SALEM LAKE DR STE F
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5292
Practice Address - Country:US
Practice Address - Phone:847-719-2220
Practice Address - Fax:847-719-2265
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023025363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2020168333OtherBOARD CERT
IL209023025Medicaid