Provider Demographics
NPI:1366810632
Name:PATEL, VELISA J (NP)
Entity type:Individual
Prefix:
First Name:VELISA
Middle Name:J
Last Name:PATEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8201 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-2300
Mailing Address - Country:US
Mailing Address - Phone:815-971-4066
Mailing Address - Fax:815-971-9299
Practice Address - Street 1:3535 N BELL SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6624
Practice Address - Country:US
Practice Address - Phone:779-696-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013285363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366810632Medicaid