Provider Demographics
NPI:1407979438
Name:NASRA, JOANNE ADEL (JN24740803P)
Entity Type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:ADEL
Last Name:NASRA
Suffix:
Gender:F
Credentials:JN24740803P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16136 BENT GRASS DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4630
Mailing Address - Country:US
Mailing Address - Phone:815-483-7171
Mailing Address - Fax:815-834-2565
Practice Address - Street 1:16136 BENT GRASS DRIVE
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441
Practice Address - Country:US
Practice Address - Phone:815-483-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist