Healthcare Provider Details

I. General information

NPI: 1770103442
Provider Name (Legal Business Name): KATLYN KAPPEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 7-701
CHICAGO IL
60611-2927
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 7-701
CHICAGO IL
60611-2927
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7950
  • Fax: 312-926-4771
Mailing address:
  • Phone: 312-695-7950
  • Fax: 312-926-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008263
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: