Provider Demographics
NPI:1265195796
Name:MANDHARE, ARCHANA (NP)
Entity type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:MANDHARE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ARCHANA
Other - Middle Name:
Other - Last Name:BHOSAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:877-448-3627
Mailing Address - Fax:866-507-1164
Practice Address - Street 1:15474 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4893
Practice Address - Country:US
Practice Address - Phone:877-448-3627
Practice Address - Fax:866-507-1164
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG07210186363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology