Provider Demographics
NPI:1043752918
Name:MASELLA, KATHLEEN (RN, AGNP-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MASELLA
Suffix:
Gender:F
Credentials:RN, AGNP-C
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:ODAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1101 S STATE ST
Mailing Address - Street 2:603
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3175
Mailing Address - Country:US
Mailing Address - Phone:773-230-8726
Mailing Address - Fax:224-610-7096
Practice Address - Street 1:1101 S STATE ST
Practice Address - Street 2:603
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3175
Practice Address - Country:US
Practice Address - Phone:773-230-8726
Practice Address - Fax:224-610-7096
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015111163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice