Healthcare Provider Details

I. General information

NPI: 1154107845
Provider Name (Legal Business Name): KENDALL R MOSBY-THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S FAIRFIELD AVE
CHICAGO IL
60608-1782
US

IV. Provider business mailing address

1713 W WALLEN AVE
CHICAGO IL
60626-5585
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-4750
  • Fax:
Mailing address:
  • Phone: 773-653-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209028233
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041403454
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: