Healthcare Provider Details

I. General information

NPI: 1225619026
Provider Name (Legal Business Name): NICOLETTA A KIJAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/05/2026
Certification Date: 04/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

150 HARVESTER DR STE 300
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5360
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1225619026
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: