Healthcare Provider Details

I. General information

NPI: 1053530998
Provider Name (Legal Business Name): KELSEY JANE FERNANDEZ L. AC.- NMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7627 LAKE ST STE 201
RIVER FOREST IL
60305-1878
US

IV. Provider business mailing address

7627 LAKE ST STE 201
RIVER FOREST IL
60305-1878
US

V. Phone/Fax

Practice location:
  • Phone: 708-689-0473
  • Fax: 708-395-2641
Mailing address:
  • Phone: 708-769-9929
  • Fax: 708-395-2641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198-000448
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: