Provider Demographics
NPI:1952885949
Name:WILEY, LARETTA MONIEK (MSN, RN, FNP)
Entity Type:Individual
Prefix:
First Name:LARETTA
Middle Name:MONIEK
Last Name:WILEY
Suffix:
Gender:F
Credentials:MSN, RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21224 GRAY HAWK DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3314
Mailing Address - Country:US
Mailing Address - Phone:773-814-3885
Mailing Address - Fax:
Practice Address - Street 1:21224 GRAY HAWK DR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3314
Practice Address - Country:US
Practice Address - Phone:773-814-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily