Healthcare Provider Details

I. General information

NPI: 1487941738
Provider Name (Legal Business Name): KAITLYN MARIE CHIERO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN MARIE BAST PA-C

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WALL ST
KANKAKEE IL
60901-2901
US

IV. Provider business mailing address

2000 GREEN RD SUITE 300
ANN ARBOR MI
48105-1598
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-1671
  • Fax:
Mailing address:
  • Phone: 734-995-3764
  • Fax: 734-995-2913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004048
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: