Provider Demographics
NPI:1184276297
Name:NIEMASZYK, KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NIEMASZYK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1700 LUTHER LN STE 1170
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1270
Practice Address - Country:US
Practice Address - Phone:844-376-3876
Practice Address - Fax:847-723-2041
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007097207T00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant