Healthcare Provider Details

I. General information

NPI: 1164129458
Provider Name (Legal Business Name): REBECCA GLORIA SHAH APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBECCA GLORIA BERNARDI APN-CNP

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 E 95TH ST
CHICAGO IL
60617-4708
US

IV. Provider business mailing address

PO BOX 1541
NORTHBROOK IL
60065-1541
US

V. Phone/Fax

Practice location:
  • Phone: 773-977-7256
  • Fax:
Mailing address:
  • Phone: 847-386-7744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209027158
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.027158
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041459161
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: