Provider Demographics
NPI:1043939747
Name:BASIC, KATRINA LEE (FNP-C, EMT-P)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LEE
Last Name:BASIC
Suffix:
Gender:F
Credentials:FNP-C, EMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11009 S SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3321
Mailing Address - Country:US
Mailing Address - Phone:773-710-2569
Mailing Address - Fax:
Practice Address - Street 1:11009 S SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3321
Practice Address - Country:US
Practice Address - Phone:773-710-2569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000471490146L00000X
IL41.420072163W00000X
IL209.025190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163W00000XNursing Service ProvidersRegistered Nurse