Provider Demographics
NPI:1922649821
Name:MUDIE, KRISTI LYNN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:MUDIE
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 1:233 E SUPERIOR ST FL 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2913
Mailing Address - Country:US
Mailing Address - Phone:312-472-1234
Mailing Address - Fax:312-472-6300
Practice Address - Street 1:233 E SUPERIOR ST FL 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2913
Practice Address - Country:US
Practice Address - Phone:312-472-1234
Practice Address - Fax:312-472-6300
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL209020220363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program