Provider Demographics
NPI:1598202442
Name:MANOJ, SHIMMY
Entity Type:Individual
Prefix:
First Name:SHIMMY
Middle Name:
Last Name:MANOJ
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 1:15W625 VIRGINIA LN
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1261
Mailing Address - Country:US
Mailing Address - Phone:630-744-9374
Mailing Address - Fax:
Practice Address - Street 1:15W625 VIRGINIA LN
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1261
Practice Address - Country:US
Practice Address - Phone:630-744-9374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015507363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily