Basic Information
| Provider Information | |||||||||
| NPI: | 1073188694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | PRIYANKA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3880 SALEM LAKE DR STE F | ||||||||
| Address2: | |||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477192220 | ||||||||
| FaxNumber: | 8477192265 | ||||||||
| Practice Location | |||||||||
| Address1: | 3880 SALEM LAKE DR # F | ||||||||
| Address2: | |||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477192200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2021 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0411426907 | IL | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 209021765 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2200X | 209021765 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 209021765 | 05 | IL | MEDICAID | MP6647157 | 01 | IL | DEA | OTHER |