Provider Demographics
NPI:1114060548
Name:MNABHI, ANETTE K (DO)
Entity Type:Individual
Prefix:DR
First Name:ANETTE
Middle Name:K
Last Name:MNABHI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-1298
Mailing Address - Country:US
Mailing Address - Phone:630-801-8773
Mailing Address - Fax:630-264-6734
Practice Address - Street 1:115 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1298
Practice Address - Country:US
Practice Address - Phone:630-801-8773
Practice Address - Fax:630-264-6734
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-103460204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4727796OtherBLUE CROSS
IL918200Medicare ID - Type Unspecified
H46209Medicare UPIN