Healthcare Provider Details

I. General information

NPI: 1538063839
Provider Name (Legal Business Name): RENATA K KAPUSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5355 W WAVELAND AVE
CHICAGO IL
60641-3354
US

IV. Provider business mailing address

5355 W WAVELAND AVE
CHICAGO IL
60641-3354
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax:
Mailing address:
  • Phone: 708-202-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043.121956
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: