MEDICARE: ILLISHA KAUR DUNLEAVY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	95019654	CA

General Provider Information

NPI Number	:	1548911639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILLISHA KAUR DUNLEAVY FNP

Provider Business Mailing Address
First Line	:	5980 CHARLOTTE DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-6809
Country	:	US
Telephone Number	:	408-507-8124
Fax Number	:

Provider Business Practice Location Address
First Line	:	2371 OWEN ST
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95054-3212
Country	:	US
Telephone Number	:	408-708-0204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	01/11/2022

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