Provider Demographics
NPI:1912050782
Name:VAEZ, KELLY ANN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:VAEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 N RAVENSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5802
Mailing Address - Country:US
Mailing Address - Phone:773-432-6570
Mailing Address - Fax:
Practice Address - Street 1:4423 N RAVENSWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5802
Practice Address - Country:US
Practice Address - Phone:773-432-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL544480Medicare ID - Type Unspecified