Provider Demographics
NPI:1770198228
Name:EIHENTALE, MALLIA
Entity type:Individual
Prefix:
First Name:MALLIA
Middle Name:
Last Name:EIHENTALE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4319
Mailing Address - Country:US
Mailing Address - Phone:773-732-8625
Mailing Address - Fax:
Practice Address - Street 1:921 DRAKE RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4319
Practice Address - Country:US
Practice Address - Phone:773-732-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily