Healthcare Provider Details

I. General information

NPI: 1184424376
Provider Name (Legal Business Name): SHAILLY BRAHMAKSHATRIYA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 TECHNOLOGY WAY STE 120
LIBERTYVILLE IL
60048-5364
US

IV. Provider business mailing address

900 TECHNOLOGY WAY STE 120
LIBERTYVILLE IL
60048-5364
US

V. Phone/Fax

Practice location:
  • Phone: 708-364-0269
  • Fax:
Mailing address:
  • Phone: 708-364-0269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-031605
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: