Provider Demographics
NPI:1225644909
Name:MODI, ROMY A (NP)
Entity Type:Individual
Prefix:MRS
First Name:ROMY
Middle Name:A
Last Name:MODI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ROMY
Other - Middle Name:A
Other - Last Name:DESAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1530 S STATE ST APT 526
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2971
Mailing Address - Country:US
Mailing Address - Phone:630-229-5882
Mailing Address - Fax:
Practice Address - Street 1:9139 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1303
Practice Address - Country:US
Practice Address - Phone:708-387-9982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily