MEDICARE: MRS. INGRID KERNIZAN WATKINS FNP-BC

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	363LF0000X	Family Nurse Practitioner	209009559	IL

General Provider Information

NPI Number	:	1225381759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. INGRID KERNIZAN WATKINS FNP-BC

Provider Business Mailing Address
First Line	:	7151 S TALMAN AVE APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-2013
Country	:	US
Telephone Number	:	773-978-5291
Fax Number	:

Provider Business Practice Location Address
First Line	:	2112 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4277
Country	:	US
Telephone Number	:	773-921-9669
Fax Number	:

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

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	10/20/2016

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