Provider Demographics
NPI:1417584541
Name:PETERSON, KYLE S (RN)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 S MICHIGAN AVE UNIT 1510
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2497
Mailing Address - Country:US
Mailing Address - Phone:815-260-4322
Mailing Address - Fax:
Practice Address - Street 1:5700 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:773-702-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041411744163WF0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WF0300XNursing Service ProvidersRegistered NurseFlight