Healthcare Provider Details

I. General information

NPI: 1548330103
Provider Name (Legal Business Name): PAMELA JEAN KOHLENBERG CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

IV. Provider business mailing address

244 LAUREL CT
HOBART IN
46342-7510
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-1574
  • Fax: 773-521-1776
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209003337
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: