Provider Demographics
NPI:1134335573
Name:EKSTROM, KATHERINE ANN (NP)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANN
Last Name:EKSTROM
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 1:5016 N MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5522
Mailing Address - Country:US
Mailing Address - Phone:312-744-5507
Mailing Address - Fax:312-744-2573
Practice Address - Street 1:2861 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5207
Practice Address - Country:US
Practice Address - Phone:312-744-5507
Practice Address - Fax:312-744-2573
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local