Healthcare Provider Details

I. General information

NPI: 1497538185
Provider Name (Legal Business Name): GIANNA MARIE PRUCHA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 N 129TH INFANTRY DR
JOLIET IL
60435-3104
US

IV. Provider business mailing address

963 N 129TH INFANTRY DR
JOLIET IL
60435-3104
US

V. Phone/Fax

Practice location:
  • Phone: 877-632-6637
  • Fax: 708-409-5179
Mailing address:
  • Phone: 877-632-6637
  • Fax: 708-409-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004588A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010068
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: