Healthcare Provider Details

I. General information

NPI: 1346746591
Provider Name (Legal Business Name): KRYS ELAN CAGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

666 DUNDEE RD STE 802
NORTHBROOK IL
60062-2734
US

IV. Provider business mailing address

114 GLENWOOD DR
ROUND LAKE BEACH IL
60073-2624
US

V. Phone/Fax

Practice location:
  • Phone: 847-498-1515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.387249
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: