Healthcare Provider Details

I. General information

NPI: 1639502230
Provider Name (Legal Business Name): GAIL GANNON APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9697 191ST ST STE 100
MOKENA IL
60448-8609
US

IV. Provider business mailing address

180 HARVESTER DR SUITE 110
BURR RIDGE IL
60527-7594
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-6540
  • Fax: 306-646-6542
Mailing address:
  • Phone: 773-834-7857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277001307
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277001307
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: