Provider Demographics
NPI:1740059369
Name:KELLY, CAITLIN (NP)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5005 N LAWNDALE AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5517
Mailing Address - Country:US
Mailing Address - Phone:630-803-8128
Mailing Address - Fax:
Practice Address - Street 1:160 E ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5426
Practice Address - Country:US
Practice Address - Phone:312-477-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029065363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health