Provider Demographics
NPI:1427478049
Name:KOTTACKAL, ALLISON (FNP)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:KOTTACKAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3036
Mailing Address - Country:US
Mailing Address - Phone:269-926-0015
Mailing Address - Fax:269-281-4475
Practice Address - Street 1:1022 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3036
Practice Address - Country:US
Practice Address - Phone:269-926-0015
Practice Address - Fax:269-281-4475
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily