Healthcare Provider Details

I. General information

NPI: 1477942118
Provider Name (Legal Business Name): MRS. MITOHOLI SUU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 69TH ST
CHICAGO IL
60621-3719
US

IV. Provider business mailing address

977 N OAKLAWN AVE SUITE 104
ELMHURST IL
60126-1045
US

V. Phone/Fax

Practice location:
  • Phone: 773-487-1200
  • Fax:
Mailing address:
  • Phone: 630-832-1775
  • Fax: 630-832-3078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209012123
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209012123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: