Provider Demographics
NPI:1902854607
Name:POWERS, KIMBERLY E THORMANN (MA CPNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E THORMANN
Last Name:POWERS
Suffix:
Gender:F
Credentials:MA CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 30
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-3582
Mailing Address - Fax:312-227-4868
Practice Address - Street 1:225 E CHICAGO AVE # 30
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-3582
Practice Address - Fax:312-227-4868
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001442208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q63867Medicare UPIN
ILK25380Medicare ID - Type Unspecified