Provider Demographics
NPI:1689005316
Name:ETHAKATTU, SOSIMOL JOSEPH (NP)
Entity Type:Individual
Prefix:MRS
First Name:SOSIMOL
Middle Name:JOSEPH
Last Name:ETHAKATTU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5132 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2429
Mailing Address - Country:US
Mailing Address - Phone:847-235-6130
Mailing Address - Fax:847-941-0577
Practice Address - Street 1:6601 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4515
Practice Address - Country:US
Practice Address - Phone:847-647-9875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily