Healthcare Provider Details

I. General information

NPI: 1568290252
Provider Name (Legal Business Name): YAMINI BODDU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N HARLEM AVE
CHICAGO IL
60707-4303
US

IV. Provider business mailing address

1625 N HARLEM AVE
CHICAGO IL
60707-4303
US

V. Phone/Fax

Practice location:
  • Phone: 708-312-0360
  • Fax:
Mailing address:
  • Phone: 708-312-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.030001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: