Healthcare Provider Details

I. General information

NPI: 1366061616
Provider Name (Legal Business Name): KRISTA KIRK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S YORK ST STE 2000
ELMHURST IL
60126-5634
US

IV. Provider business mailing address

4201 WINFIELD RD FL 3
WARRENVILLE IL
60555-4025
US

V. Phone/Fax

Practice location:
  • Phone: 331-221-9003
  • Fax:
Mailing address:
  • Phone: 331-221-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209022007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041.416140
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: