Provider Demographics
NPI:1477213825
Name:PRABHAT, ANGEL R (CLC, CALS)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:R
Last Name:PRABHAT
Suffix:
Gender:F
Credentials:CLC, CALS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 W MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4116
Mailing Address - Country:US
Mailing Address - Phone:773-724-9540
Mailing Address - Fax:
Practice Address - Street 1:5430 W MELROSE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4116
Practice Address - Country:US
Practice Address - Phone:773-724-9540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN