Healthcare Provider Details

I. General information

NPI: 1326460452
Provider Name (Legal Business Name): KIMBERLY VANDER PLOEG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST PICU
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

1775 DEMPSTER ST PICU
PARK RIDGE IL
60068-1143
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-8316
  • Fax: 847-723-1501
Mailing address:
  • Phone: 847-723-8316
  • Fax: 847-723-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number209004154
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: