Provider Demographics
NPI:1639702509
Name:DOORN, KYLIE N (QIDP)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:N
Last Name:DOORN
Suffix:
Gender:F
Credentials:QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5097 N ELSTON AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2460
Mailing Address - Country:US
Mailing Address - Phone:708-606-3228
Mailing Address - Fax:
Practice Address - Street 1:5080 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2459
Practice Address - Country:US
Practice Address - Phone:773-506-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator