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General NPI Number Information
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NPI Number | 1316587371
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Entity Type | Individual
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Provider Name | PHILSY JOMON EDAKARA APRN
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Gender | Female
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Dates
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Enumeration Date | 01/07/2020
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 8015 S LUELLA AVE STE 212
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City | CHICAGO
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State | IL
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Zip | 60617-1151
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Country | US
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Telephone | 773-721-0470
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Fax |
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Provider Business Mailing Address
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Address Line | 1313 HALLBERG LN
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City | PARK RIDGE
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State | IL
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Zip | 60068-1242
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Country | US
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Telephone |
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209.020369
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209.020369
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License Number State | IL
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