Healthcare Provider Details

I. General information

NPI: 1548755366
Provider Name (Legal Business Name): SUNANDA R KALE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUNANDA BORASE APN

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-2100
  • Fax: 309-663-8322
Mailing address:
  • Phone: 309-663-2100
  • Fax: 309-663-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017802
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: