Provider Demographics
NPI:1992411987
Name:BAHENA, VIRGINIA (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:
Last Name:BAHENA
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5747 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2353
Mailing Address - Country:US
Mailing Address - Phone:773-413-7264
Mailing Address - Fax:773-413-7013
Practice Address - Street 1:5747 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2353
Practice Address - Country:US
Practice Address - Phone:773-413-7264
Practice Address - Fax:773-413-7013
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025213363LF0000X
IL2023019943363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily