Provider Demographics
NPI:1619923315
Name:CUNNINGHAM, KATHERINE LOUISE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LOUISE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:LOUISE
Other - Last Name:HUCKABY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:111 S MORGAN ST
Mailing Address - Street 2:APT 915
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2724
Mailing Address - Country:US
Mailing Address - Phone:773-474-6855
Mailing Address - Fax:
Practice Address - Street 1:2266 N LINCOLN AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3718
Practice Address - Country:US
Practice Address - Phone:773-281-3670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002689363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ70061Medicare UPIN