Healthcare Provider Details

I. General information

NPI: 1225806110
Provider Name (Legal Business Name): KELLY MASULA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 S WABASH AVE STE 200
CHICAGO IL
60605-2348
US

IV. Provider business mailing address

0S553 FOREST ST
WINFIELD IL
60190-1541
US

V. Phone/Fax

Practice location:
  • Phone: 312-929-9191
  • Fax:
Mailing address:
  • Phone: 858-524-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209027496
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: