Provider Demographics
NPI:1942690672
Name:NORTHWESTERN MEMORIAL HEALTHCARE
Entity Type:Organization
Organization Name:NORTHWESTERN MEMORIAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITONER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, MSN, FNP
Authorized Official - Phone:847-471-3513
Mailing Address - Street 1:1030 N WOLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5986
Mailing Address - Country:US
Mailing Address - Phone:847-471-3513
Mailing Address - Fax:
Practice Address - Street 1:1030 N WOLCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5986
Practice Address - Country:US
Practice Address - Phone:847-471-3513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012197261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care