Healthcare Provider Details

I. General information

NPI: 1750185831
Provider Name (Legal Business Name): KELSIE LYNN HAMMAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 ILLINOIS ST
GREAT LAKES IL
60088-3120
US

IV. Provider business mailing address

1417 LAKEWOOD DR
JOLIET IL
60431-8420
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-1900
  • Fax:
Mailing address:
  • Phone: 815-715-0867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: