Healthcare Provider Details

I. General information

NPI: 1295574036
Provider Name (Legal Business Name): DHARA S PATEL FNP-C, APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 GATEWAY DR STE 100
SYCAMORE IL
60178-3192
US

IV. Provider business mailing address

1850 GATEWAY DR STE 100
SYCAMORE IL
60178-3192
US

V. Phone/Fax

Practice location:
  • Phone: 815-217-3252
  • Fax: 815-756-4941
Mailing address:
  • Phone: 815-217-3252
  • Fax: 815-756-4941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15362-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209030040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: