Healthcare Provider Details

I. General information

NPI: 1427077387
Provider Name (Legal Business Name): KATHY ANN JANUARY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHY ANN ROGERS RN

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2364 DELAWARE AVE APT A
GREAT LAKES IL
60088-2532
US

IV. Provider business mailing address

2364 DELAWARE AVE APT A
GREAT LAKES IL
60088-2532
US

V. Phone/Fax

Practice location:
  • Phone: 847-508-1799
  • Fax:
Mailing address:
  • Phone: 847-508-1799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number041-275899
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: