Provider Demographics
NPI:1063208924
Name:KANAGALA, MYTHILI JYOTHIRMAYI
Entity type:Individual
Prefix:
First Name:MYTHILI
Middle Name:JYOTHIRMAYI
Last Name:KANAGALA
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:MILESQUARE LP JOHNSON CENTER 1221 E. STATE ST.
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104
Mailing Address - Country:US
Mailing Address - Phone:815-972-1037
Mailing Address - Fax:
Practice Address - Street 1:MILESQUARE LP JOHNSON CENTER 1221 E. STATE ST.
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:815-972-1037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program