Provider Demographics
NPI:1275820227
Name:PRADEEP, MINI
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:
Last Name:PRADEEP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINI
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:49 CRAB TREE DR
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-3480
Mailing Address - Country:US
Mailing Address - Phone:630-963-9412
Mailing Address - Fax:630-963-9412
Practice Address - Street 1:1032 E OGDEN AVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8618
Practice Address - Country:US
Practice Address - Phone:630-705-1208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008767363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health