Provider Demographics
NPI:1508110347
Name:PANICKER, LATHA S (APN-BC)
Entity Type:Individual
Prefix:
First Name:LATHA
Middle Name:S
Last Name:PANICKER
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:MRS
Other - First Name:LATHA
Other - Middle Name:S
Other - Last Name:PANICKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN-BC
Mailing Address - Street 1:800 S WILMETTE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-8623
Mailing Address - Country:US
Mailing Address - Phone:630-696-7594
Mailing Address - Fax:
Practice Address - Street 1:977 N OAKLAWN AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1045
Practice Address - Country:US
Practice Address - Phone:800-683-7861
Practice Address - Fax:888-856-4648
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009961363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health