Healthcare Provider Details

I. General information

NPI: 1346798220
Provider Name (Legal Business Name): AUDREY L KON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N WESTMORELAND RD
LAKE FOREST IL
60045-1658
US

IV. Provider business mailing address

1000 N WESTMORELAND RD
LAKE FOREST IL
60045-1658
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-5600
  • Fax: 847-535-7884
Mailing address:
  • Phone: 847-234-5600
  • Fax: 847-535-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number112696
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209014899
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: