Healthcare Provider Details

I. General information

NPI: 1720760705
Provider Name (Legal Business Name): JESSICA AMINI PANAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 WARRENVILLE RD
LISLE IL
60532-1348
US

IV. Provider business mailing address

433 BARNABY DR
OSWEGO IL
60543-8678
US

V. Phone/Fax

Practice location:
  • Phone: 630-469-9200
  • Fax:
Mailing address:
  • Phone: 630-999-7542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.032196
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: