Healthcare Provider Details

I. General information

NPI: 1558304956
Provider Name (Legal Business Name): PREMA DAVID RN,MSN,NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST SUITE NO 215, 637 S WOOD ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

8151 TRIPP AVE
SKOKIE IL
60076-3249
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4600
  • Fax: 312-864-9569
Mailing address:
  • Phone: 847-676-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209-000941(41-192393
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: