Provider Demographics
NPI:1982876132
Name:CHILLIS, NIKYA
Entity Type:Individual
Prefix:
First Name:NIKYA
Middle Name:
Last Name:CHILLIS
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 1:1901 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12021 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1139
Practice Address - Country:US
Practice Address - Phone:708-671-2685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003138OtherLICENSE NUMBER