Healthcare Provider Details

I. General information

NPI: 1114415205
Provider Name (Legal Business Name): MRS. KAITLYN JAMIE LUNDGREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. KAITLYN JAMIE WHITE

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 06/06/2022
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 W IL ROUTE 60
MUNDELEIN IL
60060-4271
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-837-8442
  • Fax: 847-837-8542
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017501
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: