Provider Demographics
NPI:1528252061
Name:WILEY, CLEAUQUITA (APN)
Entity type:Individual
Prefix:
First Name:CLEAUQUITA
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 W 97TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2733
Mailing Address - Country:US
Mailing Address - Phone:773-732-3770
Mailing Address - Fax:
Practice Address - Street 1:2727 W 97TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2733
Practice Address - Country:US
Practice Address - Phone:773-732-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2022-02-16
Deactivation Date:2021-12-16
Deactivation Code:
Reactivation Date:2022-01-26
Provider Licenses
StateLicense IDTaxonomies
IL041-353003163WH0200X
IL209.024630363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WH0200XNursing Service ProvidersRegistered NurseHome Health