Healthcare Provider Details

I. General information

NPI: 1528306008
Provider Name (Legal Business Name): PETULA SHARMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PETULA MOUSTOGIANNIS SHARMA

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N CASS AVE
WESTMONT IL
60559-1503
US

IV. Provider business mailing address

709 BROUGHAM LN
OAK BROOK IL
60523-2676
US

V. Phone/Fax

Practice location:
  • Phone: 630-968-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.010135
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: