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General NPI Number Information
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NPI Number | 1578173613
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Entity Type | Individual
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Provider Name | NEEMA ROSE MANAPPURAM PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/04/2020
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Last Update Date | 07/21/2021
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Provider Practice Location Address
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Address Line | 3533 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647-7573
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Country | US
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Telephone | 872-269-3352
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Fax |
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Provider Business Mailing Address
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Address Line | 3533 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647-7573
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Country | US
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Telephone | 773-388-1600
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085007816
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License Number State | IL
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