MEDICARE: NICOLE KENNEBECK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085008879	IL

General Provider Information

NPI Number	:	1013680321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE KENNEBECK PA-C

Provider Business Mailing Address
First Line	:	251 E HURON ST FL 14
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2908
Country	:	US
Telephone Number	:	312-926-9843
Fax Number	:	312-926-8119

Provider Business Practice Location Address
First Line	:	251 E HURON ST FL 14
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2908
Country	:	US
Telephone Number	:	312-926-9843
Fax Number	:	312-926-8119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2021
Last Update Date	:	02/09/2026

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