Healthcare Provider Details

I. General information

NPI: 1588201719
Provider Name (Legal Business Name): STEPHANIE KAPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 N BROADWAY SUITE 900, 910, 925
CHICAGO IL
60640
US

IV. Provider business mailing address

2408 W RICE ST APT 302
CHICAGO IL
60622-5212
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-2780
  • Fax:
Mailing address:
  • Phone: 630-439-4996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.020566
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: