MEDICARE: TERESA WYATT KODIAK APN-CNP, 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	363LF0000X	Family Nurse Practitioner	219010786	IL

General Provider Information

NPI Number	:	1902236912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA WYATT KODIAK APN-CNP, FNP-C

Provider Business Mailing Address
First Line	:	611 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4911
Country	:	US
Telephone Number	:	773-570-3382
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4911
Country	:	US
Telephone Number	:	773-570-3382
Fax Number	:

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

Provider Enumeration Date	:	11/13/2013
Last Update Date	:	03/24/2017

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