Provider Demographics
NPI:1558043521
Name:OOMMEN, MINI JOY
Entity type:Individual
Prefix:
First Name:MINI
Middle Name:JOY
Last Name:OOMMEN
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 1:179 TRUMPET VINE CIR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-8179
Mailing Address - Country:US
Mailing Address - Phone:773-349-0650
Mailing Address - Fax:
Practice Address - Street 1:179 TRUMPET VINE CIR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124-8179
Practice Address - Country:US
Practice Address - Phone:773-349-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily