Provider Demographics
NPI:1710425699
Name:PATEL, NISHA (APN)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 SALEM LAKE DR STE F
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:3880 SALEM LAKE DR STE F
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5292
Practice Address - Country:US
Practice Address - Phone:847-719-2220
Practice Address - Fax:847-719-2265
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015600363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209015600Medicaid
ILMP4253326OtherDEA