Provider Demographics
NPI:1114466752
Name:BURCHULADZE, MANANA (FNP)
Entity Type:Individual
Prefix:
First Name:MANANA
Middle Name:
Last Name:BURCHULADZE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VILLA VERDE DR
Mailing Address - Street 2:# 215
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4173
Mailing Address - Country:US
Mailing Address - Phone:847-877-5093
Mailing Address - Fax:
Practice Address - Street 1:3295 N ARLINGTON HEIGHTS RD STE 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON HTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1588
Practice Address - Country:US
Practice Address - Phone:847-877-5093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily