Healthcare Provider Details

I. General information

NPI: 1346172921
Provider Name (Legal Business Name): MISS KIMBERLY COY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2026
Last Update Date: 05/30/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 173RD ST
HAZEL CREST IL
60429-1701
US

IV. Provider business mailing address

2829 173RD ST
HAZEL CREST IL
60429-1701
US

V. Phone/Fax

Practice location:
  • Phone: 708-574-1342
  • Fax:
Mailing address:
  • Phone: 708-574-1342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020.018465
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: