Provider Demographics
NPI:1568200251
Name:WONG, JONATHAN DAVID (DNP, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:WONG
Suffix:
Gender:M
Credentials:DNP, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1379 OSAGE ORANGE RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3524
Mailing Address - Country:US
Mailing Address - Phone:847-643-6253
Mailing Address - Fax:
Practice Address - Street 1:2323 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-3312
Practice Address - Country:US
Practice Address - Phone:847-666-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.497428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily