Healthcare Provider Details

I. General information

NPI: 1295203768
Provider Name (Legal Business Name): GAYATHRI S. MOORTHY APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. KELLOGG CANCER CENTER
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE. KELLOGG CANCER CENTER
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2112
  • Fax: 847-570-1041
Mailing address:
  • Phone: 847-570-2112
  • Fax: 847-570-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041403571
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018439
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: