MEDICARE: MISS KIRSTEN ELIZABETH PELKA NP

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	209.009656	IL

General Provider Information

NPI Number	:	1639413974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KIRSTEN ELIZABETH PELKA NP

Provider Business Mailing Address
First Line	:	5425 W ADDISON ST
Second Line	:	OLD IRVING PARK COMMUNITY CLINIC
City	:	CHICAGO
State	:	IL
Zip	:	60641-3203
Country	:	US
Telephone Number	:	773-427-0298
Fax Number	:

Provider Business Practice Location Address
First Line	:	5425 W ADDISON ST
Second Line	:	OLD IRVING PARK COMMUNITY CLINIC
City	:	CHICAGO
State	:	IL
Zip	:	60641-3203
Country	:	US
Telephone Number	:	773-427-0298
Fax Number	:

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

Provider Enumeration Date	:	11/26/2012
Last Update Date	:	11/26/2012

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