Healthcare Provider Details

I. General information

NPI: 1750307963
Provider Name (Legal Business Name): MARIANNE KWIATKOWSKI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W 63D STREET
CHICAGO IL
60621
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 773-377-7304
  • Fax: 773-634-7965
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.001854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: