Basic Information
| Provider Information | |||||||||
| NPI: | 1104859818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORTWIG | ||||||||
| FirstName: | DEYAN | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185075 | ||||||||
| FaxNumber: | 8476183259 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185075 | ||||||||
| FaxNumber: | 8476183259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209-003571 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209003571 | 01 | IL | STATE LICENSE | OTHER |