MEDICARE: MS. KELLY LYDON APN-CNP

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	363L00000X	Nurse Practitioner	209021740	IL
2	363LF0000X	Family Nurse Practitioner	209.02174	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	209.021740	OTHER	IL	APN LICENSE NUMBER

General Provider Information

NPI Number	:	1891308060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY LYDON APN-CNP

Provider Business Mailing Address
First Line	:	255 N ADDISON AVE APT 439
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-1629
Country	:	US
Telephone Number	:	773-503-7230
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 BIESTERFIELD RD
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3361
Country	:	US
Telephone Number	:	847-981-3599
Fax Number	:

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

Provider Enumeration Date	:	08/27/2020
Last Update Date	:	04/10/2026

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