Healthcare Provider Details

I. General information

NPI: 1699472308
Provider Name (Legal Business Name): KRYSTAL AGNEW DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

17200 PRINCE DR
SOUTH HOLLAND IL
60473-3683
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 773-559-9923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209026464
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: