Provider Demographics
NPI:1770057440
Name:GUMMADI, NIKITA SARATH (FNP-BC)
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:SARATH
Last Name:GUMMADI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 N MARINE DR APT 1407
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3996
Mailing Address - Country:US
Mailing Address - Phone:847-791-2915
Mailing Address - Fax:
Practice Address - Street 1:3450 OAKTON ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2951
Practice Address - Country:US
Practice Address - Phone:773-401-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018623363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care