Healthcare Provider Details

I. General information

NPI: 1851937643
Provider Name (Legal Business Name): KATELYN KUPER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 708-684-7032
  • Fax:
Mailing address:
  • Phone: 815-931-2844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.020548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: