MEDICARE: MRS. KELLY ANN VAEZ FNP

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	363LF0000X	Family Nurse Practitioner	277002141	IL

General Provider Information

NPI Number	:	1912050782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY ANN VAEZ FNP

Provider Business Mailing Address
First Line	:	4423 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5802
Country	:	US
Telephone Number	:	773-432-6570
Fax Number	:

Provider Business Practice Location Address
First Line	:	4423 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5802
Country	:	US
Telephone Number	:	773-432-6570
Fax Number	:

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	11/02/2023

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