Healthcare Provider Details

I. General information

NPI: 1124215264
Provider Name (Legal Business Name): KUNJUMOL PULLATHRA VELAYUDHAN ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 W 95TH ST
EVERGREEN PARK IL
60805-2108
US

IV. Provider business mailing address

3650 W 95TH ST
EVERGREEN PARK IL
60805-2108
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-7715
  • Fax: 708-422-7816
Mailing address:
  • Phone: 708-422-7715
  • Fax: 708-422-7816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209006239
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: