Provider Demographics
NPI:1649961509
Name:VELLANIKAL, RUBY
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:VELLANIKAL
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 1:1520 SUMTER CT
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5155
Mailing Address - Country:US
Mailing Address - Phone:847-532-4334
Mailing Address - Fax:
Practice Address - Street 1:1520 SUMTER CT
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5155
Practice Address - Country:US
Practice Address - Phone:847-532-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.333903163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice