MEDICARE: MRS. VALSAMMA EETTICKAL

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	363LA2200X	Adult Health Nurse Practitioner	209010753	IL

General Provider Information

NPI Number	:	1871921304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VALSAMMA EETTICKAL

Provider Business Mailing Address
First Line	:	828 SPRING VALLEY CT
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60193-4300
Country	:	US
Telephone Number	:	847-524-4211
Fax Number	:

Provider Business Practice Location Address
First Line	:	828 SPRING VALLEY CT
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60193-4300
Country	:	US
Telephone Number	:	847-524-4211
Fax Number	:

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

Provider Enumeration Date	:	10/18/2013
Last Update Date	:	10/22/2013

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