Healthcare Provider Details

I. General information

NPI: 1598628067
Provider Name (Legal Business Name): MANJU BENNY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 E IRONWOOD DR
MOUNT PROSPECT IL
60056-1359
US

IV. Provider business mailing address

913 E IRONWOOD DR
MOUNT PROSPECT IL
60056-1359
US

V. Phone/Fax

Practice location:
  • Phone: 847-863-1179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209034081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: