Provider Demographics
NPI:1912554932
Name:CUNNINGHAM, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E SUPERIOR ST STE 4-420
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2914
Mailing Address - Country:US
Mailing Address - Phone:312-695-0990
Mailing Address - Fax:312-472-4565
Practice Address - Street 1:250 E SUPERIOR ST STE 4-420
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2914
Practice Address - Country:US
Practice Address - Phone:312-695-0990
Practice Address - Fax:312-472-4565
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant