Healthcare Provider Details

I. General information

NPI: 1255732129
Provider Name (Legal Business Name): KATHY LOUISE ROBERTS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W. POLK ST. GMC SUITE 896
CHICAGO IL
60612
US

IV. Provider business mailing address

1950 W. POLK ST. GMC SUITE 896
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 312-864-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.011721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: