Healthcare Provider Details

I. General information

NPI: 1861812430
Provider Name (Legal Business Name): ELAMMA CHOLLAMPEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1900 W POLK ST STE 1200
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-3112
  • Fax:
Mailing address:
  • Phone: 312-864-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.010970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: