Healthcare Provider Details

I. General information

NPI: 1083159982
Provider Name (Legal Business Name): NANETTE KOTZ-JOOB N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2016
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 W WILSON AVE
CHICAGO IL
60640-5255
US

IV. Provider business mailing address

1945 W WILSON AVE
CHICAGO IL
60640-5255
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-6220
  • Fax: 773-736-6220
Mailing address:
  • Phone: 773-736-6220
  • Fax: 773-736-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.007900
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: