Provider Demographics
NPI:1679933527
Name:KISSANE, KEVIN (ACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:KISSANE
Suffix:
Gender:M
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1647
Mailing Address - Country:US
Mailing Address - Phone:630-207-5386
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-5878
Practice Address - Fax:312-942-8021
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002655363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care