Provider Demographics
NPI:1104339910
Name:SANNAREDDY, SWETHA (PA)
Entity type:Individual
Prefix:
First Name:SWETHA
Middle Name:
Last Name:SANNAREDDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 FARMGATE DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5930
Mailing Address - Country:US
Mailing Address - Phone:217-521-9414
Mailing Address - Fax:
Practice Address - Street 1:115 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545-1417
Practice Address - Country:US
Practice Address - Phone:630-552-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant