Healthcare Provider Details

I. General information

NPI: 1356433239
Provider Name (Legal Business Name): KATHLEEN S PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 EMERSON ST
EVANSTON IL
60208-4000
US

IV. Provider business mailing address

1601 W CHASE AVE
CHICAGO IL
60626-2507
US

V. Phone/Fax

Practice location:
  • Phone: 847-491-8100
  • Fax:
Mailing address:
  • Phone: 773-743-5232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209000562
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: