Healthcare Provider Details

I. General information

NPI: 1760395636
Provider Name (Legal Business Name): KAITLYN MULLIGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PFINGSTEN RD
GLENVIEW IL
60026-1301
US

IV. Provider business mailing address

2718 W ROSCOE ST
CHICAGO IL
60618-5910
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: