Basic Information
| Provider Information | |||||||||
| NPI: | 1366810632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | VELISA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159714066 | ||||||||
| FaxNumber: | 8159719299 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159714066 | ||||||||
| FaxNumber: | 8159719299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209013285 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1366810632 | 05 | WI | MEDICAID |