Provider Demographics
NPI:1295203768
Name:MOORTHY, GAYATHRI S (APN-CNP)
Entity Type:Individual
Prefix:MS
First Name:GAYATHRI
Middle Name:S
Last Name:MOORTHY
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Gender:F
Credentials:APN-CNP
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Mailing Address - Street 1:2650 RIDGE AVE.
Mailing Address - Street 2:KELLOGG CANCER CENTER
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2112
Mailing Address - Fax:847-570-1041
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:KELLOGG CANCER CENTER
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2112
Practice Address - Fax:847-570-1041
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL041403571163W00000X
IL209018439363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse