Provider Demographics
NPI:1588763395
Name:REDDICK, DENA KAY (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:DENA
Middle Name:KAY
Last Name:REDDICK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:DENA
Other - Middle Name:KAY
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 RIVERSIDE DR STE 2800
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5004
Mailing Address - Country:US
Mailing Address - Phone:815-935-1100
Mailing Address - Fax:815-937-5966
Practice Address - Street 1:400 RIVERSIDE DR STE 2800
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5004
Practice Address - Country:US
Practice Address - Phone:815-935-1100
Practice Address - Fax:815-937-5966
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001955363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP54264Medicare UPIN
ILK33870Medicare PIN