Healthcare Provider Details

I. General information

NPI: 1437431772
Provider Name (Legal Business Name): KIMBERLY NICOLE LAVELLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

231 E FREMONT AVE APT 104
ELMHURST IL
60126-2400
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax:
Mailing address:
  • Phone: 847-774-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-004129
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: