Basic Information
| Provider Information | |||||||||
| NPI: | 1588063994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASSIDY | ||||||||
| FirstName: | GWEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 N SAINT CLAIR ST | ||||||||
| Address2: | 17TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126955620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST | ||||||||
| Address2: | 17TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126955620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2014 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
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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 | 363LA2100X | 209011722 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.