Provider Demographics
NPI:1376218859
Name:KELSEY JEDRZEJAK, AMANDA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KELSEY JEDRZEJAK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10604 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2704
Mailing Address - Country:US
Mailing Address - Phone:708-424-9710
Mailing Address - Fax:
Practice Address - Street 1:10604 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2704
Practice Address - Country:US
Practice Address - Phone:708-424-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily