Basic Information
| Provider Information | |||||||||
| NPI: | 1003299165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANAMBO | ||||||||
| FirstName: | JULIET | ||||||||
| MiddleName: | IBANEZ | ||||||||
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| Credential: | AGPCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5258 S DREXEL AVE | ||||||||
| Address2: | 1F | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606153752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122084962 | ||||||||
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| Practice Location | |||||||||
| Address1: | PO BOX 745 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601260745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304001575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209012519 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 209.012519 | 01 | IL | STATE LICENSE APN | OTHER |