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General NPI Number Information
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NPI Number | 1215510987
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Entity Type | Individual
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Provider Name | AJIE JIBU MAMMARAPPALLIL AGACNP
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Gender | Female
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Dates
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Enumeration Date | 04/30/2021
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Last Update Date | 04/30/2021
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Provider Practice Location Address
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Address Line | 12251 S 80TH AVE
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1290
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Country | US
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Telephone | 708-923-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 17704 RADCLIFFE CT
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City | TINLEY PARK
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State | IL
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Zip | 60487-2291
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Country | US
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Telephone | 312-833-6055
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 209022913
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 209022913
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License Number State | IL
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