Healthcare Provider Details

I. General information

NPI: 1659080380
Provider Name (Legal Business Name): SWARNA GUMMADI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 08/20/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 TELSER RD UNIT 1057
LAKE ZURICH IL
60047-3647
US

IV. Provider business mailing address

62 KETTELL AVE
YONKERS NY
10704-2211
US

V. Phone/Fax

Practice location:
  • Phone: 847-847-1393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041541780
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN2348431
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209027141
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: