Healthcare Provider Details

I. General information

NPI: 1598207375
Provider Name (Legal Business Name): SHENCY VARUGHESE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2361 PAYSPHERE CIR
CHICAGO IL
60674
US

IV. Provider business mailing address

2520 ELISHA AVE
ZION IL
60099
US

V. Phone/Fax

Practice location:
  • Phone: 847-746-4358
  • Fax: 847-526-2017
Mailing address:
  • Phone: 847-872-4561
  • Fax: 847-526-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015118
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041294348
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.015118
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: