Provider Demographics
NPI:1104589209
Name:GABHAWALA, PURVI (AGNP)
Entity type:Individual
Prefix:
First Name:PURVI
Middle Name:
Last Name:GABHAWALA
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 SANDHURST LN
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-4348
Mailing Address - Country:US
Mailing Address - Phone:631-605-2916
Mailing Address - Fax:
Practice Address - Street 1:150 N RIVER RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1272
Practice Address - Country:US
Practice Address - Phone:847-290-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024148363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health