=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477942118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MITOHOLI SUU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2015
-----------------------------------------------------
Last Update Date | 01/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W 69TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60621-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-487-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 977 N OAKLAWN AVE SUITE 104
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-1045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-832-1775
-----------------------------------------------------
Fax | 630-832-3078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 209012123
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 209012123
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------