Provider Demographics
NPI:1790319630
Name:EKHOFF, KRYSTLE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:EKHOFF
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9108 S TROY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1628
Mailing Address - Country:US
Mailing Address - Phone:773-241-4497
Mailing Address - Fax:
Practice Address - Street 1:9108 S TROY AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1628
Practice Address - Country:US
Practice Address - Phone:773-241-4497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-01
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.453125164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse