Provider Demographics
NPI:1154676625
Name:POUPORE, KATLYN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATLYN
Middle Name:
Last Name:POUPORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:KATLYN
Other - Middle Name:
Other - Last Name:SZYMCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:6110 N OTTAWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3813
Mailing Address - Country:US
Mailing Address - Phone:773-391-7381
Mailing Address - Fax:
Practice Address - Street 1:3 ERIE CT
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2519
Practice Address - Country:US
Practice Address - Phone:708-763-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04138163163W00000X
IL209013226363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily