Provider Demographics
NPI:1497721971
Name:NICOLETTO, KRISTINE M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:M
Last Name:NICOLETTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S BIESTERFIELD RD
Mailing Address - Street 2:ALEXIAN BROTHERS EMERGENCY DEPT
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007
Mailing Address - Country:US
Mailing Address - Phone:847-981-3599
Mailing Address - Fax:
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-981-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002307363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25094/208534Medicare ID - Type Unspecified
ILQ63204Medicare UPIN