Healthcare Provider Details

I. General information

NPI: 1114390788
Provider Name (Legal Business Name): KATHERINE EYDELMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE TONNIES

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 S STATE ST
CHICAGO IL
60609-3701
US

IV. Provider business mailing address

4318 S STATE ST
CHICAGO IL
60609-3701
US

V. Phone/Fax

Practice location:
  • Phone: 773-285-9304
  • Fax: 773-564-3501
Mailing address:
  • Phone: 773-285-9304
  • Fax: 773-564-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018063
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN002070
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: