Healthcare Provider Details

I. General information

NPI: 1730772633
Provider Name (Legal Business Name): KIMBERLEY A BENTELE APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATION DR STE 300
CRYSTAL LAKE IL
60014-8003
US

IV. Provider business mailing address

360 STATION DR STE 300
CRYSTAL LAKE IL
60014-8003
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-1800
  • Fax: 815-455-1875
Mailing address:
  • Phone: 815-455-1800
  • Fax: 815-455-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209022603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: