Provider Demographics
NPI:1548705056
Name:MUTYALA, KALPANA (APN)
Entity type:Individual
Prefix:
First Name:KALPANA
Middle Name:
Last Name:MUTYALA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 REMINGTON RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4832
Mailing Address - Country:US
Mailing Address - Phone:630-701-9009
Mailing Address - Fax:
Practice Address - Street 1:1355 REMINGTON RD
Practice Address - Street 2:SUITE H
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4832
Practice Address - Country:US
Practice Address - Phone:630-701-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015323363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner