Provider Demographics
NPI:1821195496
Name:HILLER-KOZUBIK, THERESE MARGARET (NP)
Entity Type:Individual
Prefix:MS
First Name:THERESE
Middle Name:MARGARET
Last Name:HILLER-KOZUBIK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:MARGARET
Other - Last Name:KOZUBIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:2007 95TH ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8459
Mailing Address - Country:US
Mailing Address - Phone:630-646-6907
Mailing Address - Fax:
Practice Address - Street 1:2007 95TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8459
Practice Address - Country:US
Practice Address - Phone:630-646-6907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002502163WG0000X
IL209.002502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202303957-60504-01Medicaid
IL211319Medicare ID - Type Unspecified
IL202303957-60504-01Medicaid