Healthcare Provider Details

I. General information

NPI: 1770952764
Provider Name (Legal Business Name): KRISTIN KLEIDERER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2015
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9977 WOODS DR
SKOKIE IL
60077
US

IV. Provider business mailing address

9977 WOODS DR
SKOKIE IL
60077-1057
US

V. Phone/Fax

Practice location:
  • Phone: 224-364-2273
  • Fax:
Mailing address:
  • Phone: 224-364-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041.371380
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.012081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: