Provider Demographics
NPI:1508955394
Name:TODD, KRISTY (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:TODD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5841 S. MARYLAND AVE.
Mailing Address - Street 2:MC 5040, SUITE E500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637
Mailing Address - Country:US
Mailing Address - Phone:773-702-5267
Mailing Address - Fax:773-702-4187
Practice Address - Street 1:5841 S. MARYLAND AVE.
Practice Address - Street 2:MC 5040, SUITE E500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-5267
Practice Address - Fax:773-834-9114
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant