Healthcare Provider Details

I. General information

NPI: 1336316603
Provider Name (Legal Business Name): KATHLEEN ANN KOCIAK RN, MS, GNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W 95TH ST SUITE 106
EVERGREEN PARK IL
60805-2735
US

IV. Provider business mailing address

2800 W 87TH ST
CHICAGO IL
60652-3831
US

V. Phone/Fax

Practice location:
  • Phone: 708-425-9399
  • Fax:
Mailing address:
  • Phone: 773-863-7503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209-004338
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: