Provider Demographics
NPI:1497443915
Name:RAZA, KATHLEEN (AGACNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RAZA
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 REBECCA LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4861
Mailing Address - Country:US
Mailing Address - Phone:630-398-6191
Mailing Address - Fax:
Practice Address - Street 1:396 REMINGTON BLVD STE 140
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4311
Practice Address - Country:US
Practice Address - Phone:630-495-9356
Practice Address - Fax:630-495-9357
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0123456789363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care