Provider Demographics
NPI:1750307963
Name:KWIATKOWSKI, MARIANNE (NP)
Entity Type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:
Last Name:KWIATKOWSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:850 W 63D STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621
Practice Address - Country:US
Practice Address - Phone:773-377-7304
Practice Address - Fax:773-634-7965
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP12760Medicare UPIN
ILL96593Medicare ID - Type Unspecified