Healthcare Provider Details

I. General information

NPI: 1043752918
Provider Name (Legal Business Name): KATHLEEN MASELLA R.N., AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHY ODAY RN

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 GROSS POINT RD STE 700
SKOKIE IL
60077-1864
US

IV. Provider business mailing address

1101 S STATE ST APT 603
CHICAGO IL
60605-3178
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5500
  • Fax: 773-296-3800
Mailing address:
  • Phone: 773-230-8726
  • Fax: 224-610-7096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209015111
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: