Provider Demographics
NPI:1790258473
Name:TRIVEDE, PUNAM SUBHASHCHANDRA (APN)
Entity Type:Individual
Prefix:
First Name:PUNAM
Middle Name:SUBHASHCHANDRA
Last Name:TRIVEDE
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 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:
Practice Address - Street 1:711 W JOHN GWYNN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2270
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-671-2188
Is Sole Proprietor?:No
Enumeration Date:2019-01-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018588363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209018588Medicaid
IL209018588Medicaid