Provider Demographics
NPI:1528504909
Name:CUNNINGHAM, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 CRAIN ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2408
Mailing Address - Country:US
Mailing Address - Phone:773-616-5330
Mailing Address - Fax:
Practice Address - Street 1:3300 CRAIN ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2408
Practice Address - Country:US
Practice Address - Phone:773-616-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015329363LF0000X
IL277.001291363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily