MEDICARE: MRS. KELLY DANAE VOTH AGNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	209010428	IL

General Provider Information

NPI Number	:	1386083061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY DANAE VOTH AGNP

Provider Business Mailing Address
First Line	:	2614 N WILTON AVE
Second Line	:	#1
City	:	CHICAGO
State	:	IL
Zip	:	60614-7999
Country	:	US
Telephone Number	:	620-200-1086
Fax Number	:

Provider Business Practice Location Address
First Line	:	2614 N WILTON AVE
Second Line	:	#1
City	:	CHICAGO
State	:	IL
Zip	:	60614-7999
Country	:	US
Telephone Number	:	620-200-1086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2013
Last Update Date	:	06/17/2013

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