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General NPI Number Information
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NPI Number | 1871592543
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Entity Type | Individual
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Provider Name | DR. KELLY DINEEN
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Gender | Female
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Dates
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Enumeration Date | 07/15/2005
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Last Update Date | 04/22/2020
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Provider Practice Location Address
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Address Line | 1 E DELAWARE PL STE 310
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City | CHICAGO
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State | IL
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Zip | 60611-4962
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Country | US
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Telephone | 773-720-1623
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Fax |
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Provider Business Mailing Address
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Address Line | 5250 GRAND AVE # 14-390
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City | GURNEE
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State | IL
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Zip | 60031-1877
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Country | US
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Telephone | 847-212-1015
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 071006880
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License Number State | IL
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