MEDICARE: CATHLEEN MARIE KIELY APN

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	363LP0200X	Pediatric Nurse Practitioner	209.008808	IL

General Provider Information

NPI Number	:	1588033161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CATHLEEN MARIE KIELY APN

Provider Business Mailing Address
First Line	:	840 S WOOD ST
Second Line	:	M/C 856 ROOM 1345
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-996-6143
Fax Number	:	312-413-9484

Provider Business Practice Location Address
First Line	:	840 S WOOD ST
Second Line	:	M/C 856 ROOM 1345
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-996-6143
Fax Number	:	312-413-9484

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

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	09/24/2015

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