Provider Demographics
NPI:1356790653
Name:EETTICKAL, SHEENA ALEENA (DO)
Entity type:Individual
Prefix:
First Name:SHEENA
Middle Name:ALEENA
Last Name:EETTICKAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N GARY AVE
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-1834
Mailing Address - Country:US
Mailing Address - Phone:630-360-2958
Mailing Address - Fax:630-360-2959
Practice Address - Street 1:200 N GARY AVE
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-1834
Practice Address - Country:US
Practice Address - Phone:630-360-2958
Practice Address - Fax:630-360-2959
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine