Healthcare Provider Details

I. General information

NPI: 1518448158
Provider Name (Legal Business Name): KRISTEN TRUKOVA PA-C, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVE OFC
ZION IL
60099-2676
US

IV. Provider business mailing address

2520 ELISHA AVE
ZION IL
60099-2676
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-6164
  • Fax:
Mailing address:
  • Phone: 847-872-6164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007260
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.003487
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: