Healthcare Provider Details

I. General information

NPI: 1548013360
Provider Name (Legal Business Name): KYLA LEE MASSIMB FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 WOODBURY ST
SOUTH ELGIN IL
60177-1327
US

IV. Provider business mailing address

85 WOODBURY ST
SOUTH ELGIN IL
60177-1327
US

V. Phone/Fax

Practice location:
  • Phone: 224-238-8252
  • Fax:
Mailing address:
  • Phone: 224-238-8252
  • Fax: 815-604-8076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.029912
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: