=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528600277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINA SOUTHERLAND FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2019
-----------------------------------------------------
Last Update Date | 08/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10604 SOUTHWEST HWY STE 101
-----------------------------------------------------
City | CHICAGO RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60415-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-346-4065
-----------------------------------------------------
Fax | 708-423-5799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29373 NETWORK PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-390-5900
-----------------------------------------------------
Fax | 847-390-4757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209020105
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------