Provider Demographics
NPI:1912462870
Name:ISSAC, JANZE MARIUM (ANP)
Entity Type:Individual
Prefix:MRS
First Name:JANZE
Middle Name:MARIUM
Last Name:ISSAC
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:JANZE
Other - Middle Name:MARIUM
Other - Last Name:KOSHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:650 S RIVER RD UNIT 404
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-8430
Mailing Address - Country:US
Mailing Address - Phone:845-480-2862
Mailing Address - Fax:
Practice Address - Street 1:1550 S INDIANA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-4835
Practice Address - Country:US
Practice Address - Phone:845-480-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017708363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology