Provider Demographics
NPI:1982990271
Name:DALLINGA, BREE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:BREE
Middle Name:ANN
Last Name:DALLINGA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 E LOWDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-6622
Mailing Address - Country:US
Mailing Address - Phone:207-841-9259
Mailing Address - Fax:
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:312-695-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006864363A00000X
MAPA4250363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022061BOtherGROUP MEDICAID NUMBER