Provider Demographics
NPI:1093995565
Name:KRENEK, KEVIN T (NP-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:KRENEK
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W HUBBARD ST APT 411
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5607
Mailing Address - Country:US
Mailing Address - Phone:615-429-0649
Mailing Address - Fax:
Practice Address - Street 1:360 W HUBBARD ST APT 411
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5607
Practice Address - Country:US
Practice Address - Phone:615-429-0649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPENDING363LF0000X
IL209009450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10939955665Medicare PIN