Healthcare Provider Details

I. General information

NPI: 1194285213
Provider Name (Legal Business Name): CERES K KANGOU APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9697 191ST ST. SUITE 200 EHMG-BEHAVIORAL HEALTH
MOKENA IL
60448
US

IV. Provider business mailing address

1111 W LAKE ST
ADDISON IL
60101-1197
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-6540
  • Fax: 630-646-6542
Mailing address:
  • Phone: 630-682-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019061
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277002135
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: