Healthcare Provider Details

I. General information

NPI: 1710605738
Provider Name (Legal Business Name): ELIZABETH KUPCZYK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E LINCOLN HWY
NEW LENOX IL
60451-1975
US

IV. Provider business mailing address

509 CARDINAL AVE
OSWEGO IL
60543-7765
US

V. Phone/Fax

Practice location:
  • Phone: 815-462-5544
  • Fax:
Mailing address:
  • Phone: 815-351-7909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025077
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: