Healthcare Provider Details

I. General information

NPI: 1588102305
Provider Name (Legal Business Name): TONYA LYNETTE GOLLAHALLI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE STE 467
CHICAGO IL
60631-3715
US

IV. Provider business mailing address

7447 W TALCOTT AVE STE 467
CHICAGO IL
60631-3715
US

V. Phone/Fax

Practice location:
  • Phone: 630-866-3636
  • Fax: 773-692-2035
Mailing address:
  • Phone: 630-866-3636
  • Fax: 773-692-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2733
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.009747
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: