Provider Demographics
NPI:1912646159
Name:WEATHERSBY, KRISTLIN
Entity Type:Individual
Prefix:
First Name:KRISTLIN
Middle Name:
Last Name:WEATHERSBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 W BELMONT AVE, UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:312-489-5160
Mailing Address - Fax:
Practice Address - Street 1:1551 BOND ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-0137
Practice Address - Country:US
Practice Address - Phone:312-489-5160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily