Healthcare Provider Details

I. General information

NPI: 1104339910
Provider Name (Legal Business Name): SWETHA SANNAREDDY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E SOUTH ST
PLANO IL
60545-1417
US

IV. Provider business mailing address

3323 FARMGATE DR
NAPERVILLE IL
60564-5930
US

V. Phone/Fax

Practice location:
  • Phone: 630-552-7166
  • Fax:
Mailing address:
  • Phone: 217-521-9414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006315
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: