Healthcare Provider Details

I. General information

NPI: 1770198228
Provider Name (Legal Business Name): MALLIA EIHENTALE DNP, FNP-BC, DCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8035 LINCOLN AVE
SKOKIE IL
60077-3612
US

IV. Provider business mailing address

8035 LINCOLN AVE
SKOKIE IL
60077-3612
US

V. Phone/Fax

Practice location:
  • Phone: 773-732-8625
  • Fax:
Mailing address:
  • Phone: 773-732-8625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.018102
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: