Provider Demographics
NPI:1114390788
Name:EYDELMAN, KATHERINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:
Last Name:EYDELMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:TONNIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4318 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-3701
Mailing Address - Country:US
Mailing Address - Phone:773-285-9304
Mailing Address - Fax:773-564-3501
Practice Address - Street 1:4318 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3701
Practice Address - Country:US
Practice Address - Phone:773-285-9304
Practice Address - Fax:773-564-3501
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018063363L00000X
NVAPRN002070363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1114390788Medicaid
NVPENDINGMedicare PIN