Healthcare Provider Details

I. General information

NPI: 1740754829
Provider Name (Legal Business Name): KENDRA MICHELLE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S MICHIGAN AVE
CHICAGO IL
60616-2315
US

IV. Provider business mailing address

22302 W KANKAKEE RIVER DR
WILMINGTON IL
60481-8803
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-2000
  • Fax:
Mailing address:
  • Phone: 772-502-7152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018531
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: