Provider Demographics
NPI:1497186472
Name:VAN WYNGARDEN, KIMBERLY (APRN-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VAN WYNGARDEN
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:SASVELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:17495 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487
Practice Address - Country:US
Practice Address - Phone:708-226-7000
Practice Address - Fax:708-226-7174
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011021363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300116195OtherLOCALITY 16
ILF300116196OtherLOCALITY 15
ILP01451822OtherRRMC
ILP01451822OtherRRMC
ILF300116195Medicare PIN
ILF300116196OtherLOCALITY 15