Provider Demographics
NPI:1700245438
Name:VENKATESAN, ROMA H
Entity Type:Individual
Prefix:
First Name:ROMA
Middle Name:H
Last Name:VENKATESAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROMA
Other - Middle Name:H
Other - Last Name:VENKATESAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:800 BIESTERFIELD ROAD CANCER INSTITUTE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007
Mailing Address - Country:US
Mailing Address - Phone:847-952-7929
Mailing Address - Fax:630-893-1467
Practice Address - Street 1:800 BIESTERFIELD ROAD CANCER INSTITUTE
Practice Address - Street 2:SUITE 120
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007
Practice Address - Country:US
Practice Address - Phone:847-952-7929
Practice Address - Fax:630-893-1467
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209013761Medicaid