Provider Demographics
NPI:1477942118
Name:SUU, MITOHOLI
Entity Type:Individual
Prefix:MRS
First Name:MITOHOLI
Middle Name:
Last Name:SUU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 N OAKLAWN AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1045
Mailing Address - Country:US
Mailing Address - Phone:630-832-1775
Mailing Address - Fax:630-832-3078
Practice Address - Street 1:201 W 69TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3719
Practice Address - Country:US
Practice Address - Phone:773-487-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012123363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology