Healthcare Provider Details

I. General information

NPI: 1811573264
Provider Name (Legal Business Name): COURTNEY LEE KENTALA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9650 GROSS POINT RD STE 2900
SKOKIE IL
60076-5006
US

IV. Provider business mailing address

9650 GROSS POINT RD STE 2900
SKOKIE IL
60076-5006
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax: 847-383-2210
Mailing address:
  • Phone: 847-866-7846
  • Fax: 847-383-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085009038
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: