=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770057440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKITA SARATH GUMMADI FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2019
-----------------------------------------------------
Last Update Date | 01/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3450 OAKTON ST
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-401-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4950 N MARINE DR APT 1407
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-3996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-791-2915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 209018623
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------