Provider Demographics
NPI:1063013746
Name:NALLAMILLI, LAKSHMISOWJANYA
Entity Type:Individual
Prefix:
First Name:LAKSHMISOWJANYA
Middle Name:
Last Name:NALLAMILLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11639 MILLENNIUM PKWY
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5185
Mailing Address - Country:US
Mailing Address - Phone:847-448-0236
Mailing Address - Fax:
Practice Address - Street 1:865 N CASS AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-6404
Practice Address - Country:US
Practice Address - Phone:630-400-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist