Healthcare Provider Details

I. General information

NPI: 1720491590
Provider Name (Legal Business Name): KRISTIN MARIE WESSEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5721 S MARYLAND AVE MC 8016, K155
CHICAGO IL
60637-1425
US

IV. Provider business mailing address

5721 S MARYLAND AVE MC 8016, K155
CHICAGO IL
60637-1425
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-7553
  • Fax: 773-834-0748
Mailing address:
  • Phone: 773-702-7553
  • Fax: 773-834-0748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: