Healthcare Provider Details

I. General information

NPI: 1043939747
Provider Name (Legal Business Name): KATRINA LEE BASIC FNP-C, EMT-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11009 S SAINT LOUIS AVE
CHICAGO IL
60655-3321
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 773-710-2569
  • Fax:
Mailing address:
  • Phone: 239-343-1614
  • Fax: 239-343-3695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number41.420072
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number000471490
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.025190
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: