MEDICARE: KAYLA CONRAD FNP-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	163W00000X	Registered Nurse	783207	CA
2	363LF0000X	Family Nurse Practitioner	95005582	CA
3	363LF0000X	Family Nurse Practitioner	209021842	IL

General Provider Information

NPI Number	:	1629447701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA CONRAD FNP-C

Provider Business Mailing Address
First Line	:	10551 WINDSOR DR
Second Line	:
City	:	WESTCHESTER
State	:	IL
Zip	:	60154-5328
Country	:	US
Telephone Number	:	925-949-6691
Fax Number	:

Provider Business Practice Location Address
First Line	:	8711 W CERMAK RD
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-1166
Country	:	US
Telephone Number	:	708-442-7979
Fax Number	:	708-442-8574

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

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	09/22/2020

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