Healthcare Provider Details

I. General information

NPI: 1578253878
Provider Name (Legal Business Name): GWYNETH M KELLEHER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 N WESTERN AVE STE 134
CHICAGO IL
60622-1797
US

IV. Provider business mailing address

1431 N WESTERN AVE STE 134
CHICAGO IL
60622-1797
US

V. Phone/Fax

Practice location:
  • Phone: 773-235-1915
  • Fax:
Mailing address:
  • Phone: 773-235-1915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085011293
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: