Provider Demographics
NPI:1417425547
Name:DOVERTE, KEN GABRIEL (NP)
Entity Type:Individual
Prefix:MR
First Name:KEN GABRIEL
Middle Name:
Last Name:DOVERTE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1420 RENAISSANCE DR STE 207
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1342
Mailing Address - Country:US
Mailing Address - Phone:847-296-6161
Mailing Address - Fax:847-574-7444
Practice Address - Street 1:1420 RENAISSANCE DR STE 207
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1342
Practice Address - Country:US
Practice Address - Phone:847-296-6161
Practice Address - Fax:847-574-7444
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018290363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health