Provider Demographics
NPI:1477372837
Name:KELLY, KATHERINE ROSE (DNP FNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DNP FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 W WILLOW ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5365
Mailing Address - Country:US
Mailing Address - Phone:602-391-8210
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 158
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily