Healthcare Provider Details

I. General information

NPI: 1053772178
Provider Name (Legal Business Name): KATRINA CUDAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 REMINGTON BLVD
BOLINGBROOK IL
60440-4302
US

IV. Provider business mailing address

1572 SUNCREST LN
BOLINGBROOK IL
60490-3278
US

V. Phone/Fax

Practice location:
  • Phone: 630-759-2966
  • Fax:
Mailing address:
  • Phone: 773-383-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014009
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: