Individual
KELLY A PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
225 E CHICAGO AVE, CHICAGO, IL 60611-2991
(312) 227-4000
Mailing address
12516 S 71ST CT, PALOS HEIGHTS, IL 60463-1550
(708) 768-1694
Taxonomy
Speciality
Code
Description
License number
State
363LN0005X
Critical Care Neonatal Nurse Practitioner
Primary
209.020968
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
EAD821145963
HEALTH INSURANCE
IL
Enumeration date
02/28/2020
Last updated
02/28/2020
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