Healthcare Provider Details

I. General information

NPI: 1033743653
Provider Name (Legal Business Name): KOURTNEY MILENKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3258 W 111TH ST
CHICAGO IL
60655-2729
US

IV. Provider business mailing address

8135 CALUMET AVE
MUNSTER IN
46321-1701
US

V. Phone/Fax

Practice location:
  • Phone: 773-629-8217
  • Fax:
Mailing address:
  • Phone: 219-513-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009825A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: