Provider Demographics
NPI:1487184198
Name:ACHARYA, PRAJNA
Entity Type:Individual
Prefix:
First Name:PRAJNA
Middle Name:
Last Name:ACHARYA
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 1:9007 N SCRIMSHAW DR APT 204
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7885
Mailing Address - Country:US
Mailing Address - Phone:312-608-4868
Mailing Address - Fax:
Practice Address - Street 1:2720 S 14TH ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-9621
Practice Address - Country:US
Practice Address - Phone:312-608-4868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist