Healthcare Provider Details

I. General information

NPI: 1306117767
Provider Name (Legal Business Name): ANNAMMA ABRAHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E SCHILLER ST STE 319
ELMHURST IL
60126-2823
US

IV. Provider business mailing address

1312 CHESTERFIELD LN
GRAYSLAKE IL
60030-3798
US

V. Phone/Fax

Practice location:
  • Phone: 630-832-1775
  • Fax:
Mailing address:
  • Phone: 847-231-5327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.008789
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: