Provider Demographics
NPI:1912582339
Name:BALA, STEPHEN (MSN, APRN, FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:BALA
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 SALEM LAKE DR STE F
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:3880 SALEM LAKE DR STE F
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5292
Practice Address - Country:US
Practice Address - Phone:847-719-2220
Practice Address - Fax:847-719-2265
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023030363L00000X
IL209023030363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209023030Medicaid
ILMB6546088OtherDEA