Healthcare Provider Details

I. General information

NPI: 1770057440
Provider Name (Legal Business Name): NIKITA SARATH GUMMADI FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 OAKTON ST
SKOKIE IL
60076-2951
US

IV. Provider business mailing address

4950 N MARINE DR APT 1407
CHICAGO IL
60640-3996
US

V. Phone/Fax

Practice location:
  • Phone: 773-401-4300
  • Fax:
Mailing address:
  • Phone: 847-791-2915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209018623
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: