Healthcare Provider Details

I. General information

NPI: 1497596886
Provider Name (Legal Business Name): STEPHANIE KUTELLA PMHNP - BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2024
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6943 TICONDEROGA RD
DOWNERS GROVE IL
60516-3143
US

IV. Provider business mailing address

6943 TICONDEROGA RD
DOWNERS GROVE IL
60516-3143
US

V. Phone/Fax

Practice location:
  • Phone: 224-567-0219
  • Fax:
Mailing address:
  • Phone: 224-567-0219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209030251
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: