Provider Demographics
NPI:1295599900
Name:AZAMBUJA CACHOEIRA, KELLY TAIS (APRN)
Entity type:Individual
Prefix:
First Name:KELLY TAIS
Middle Name:
Last Name:AZAMBUJA CACHOEIRA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 WAUKEGAN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1885
Mailing Address - Country:US
Mailing Address - Phone:847-444-5300
Mailing Address - Fax:
Practice Address - Street 1:2151 WAUKEGAN RD STE 100
Practice Address - Street 2:
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1885
Practice Address - Country:US
Practice Address - Phone:847-444-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029354363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner