Provider Demographics
NPI:1194008425
Name:EVANS-SNULLIGAN, KENYATTA (NP)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:EVANS-SNULLIGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KENYATTA
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1100 W CERMAK RD
Mailing Address - Street 2:CUITE C119
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4500
Mailing Address - Country:US
Mailing Address - Phone:312-243-2223
Mailing Address - Fax:312-243-2227
Practice Address - Street 1:1100 W CERMAK RD
Practice Address - Street 2:CUITE C119
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4500
Practice Address - Country:US
Practice Address - Phone:312-243-2223
Practice Address - Fax:312-243-2227
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041361698364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041361698OtherIL STATE LICENSE