Healthcare Provider Details

I. General information

NPI: 1104320894
Provider Name (Legal Business Name): KRISTEN HERMANSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 55TH ST
CHICAGO IL
60615-4906
US

IV. Provider business mailing address

225 W HURON ST APT 317
CHICAGO IL
60654-3943
US

V. Phone/Fax

Practice location:
  • Phone: 312-682-6110
  • Fax:
Mailing address:
  • Phone: 203-521-2996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.156703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: