Healthcare Provider Details

I. General information

NPI: 1083536544
Provider Name (Legal Business Name): ANIDA THOUNSAVATH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S NORTHWEST HWY
PARK RIDGE IL
60068-4243
US

IV. Provider business mailing address

8231 MENARD AVE
MORTON GROVE IL
60053-3334
US

V. Phone/Fax

Practice location:
  • Phone: 224-585-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209035515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: