Healthcare Provider Details

I. General information

NPI: 1003426149
Provider Name (Legal Business Name): JOSEPHINE KIDDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOSEPHINE P. FERREL

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 N CALIFORNIA AVE STE 220
CHICAGO IL
60618-7702
US

IV. Provider business mailing address

901 MCCLINTOCK DR STE 202
BURR RIDGE IL
60527-0872
US

V. Phone/Fax

Practice location:
  • Phone: 888-220-6432
  • Fax:
Mailing address:
  • Phone: 630-655-6748
  • Fax: 630-734-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4704287340
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: