Healthcare Provider Details

I. General information

NPI: 1497627731
Provider Name (Legal Business Name): JOHN VELUKUNNEL PATHROSE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 W DIVISION ST
CHICAGO IL
60622-2853
US

IV. Provider business mailing address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-7858
  • Fax: 773-687-9539
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.029544
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: