Provider Demographics
NPI:1447962378
Name:KING, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KING
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 1:1700 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-5500
Mailing Address - Country:US
Mailing Address - Phone:312-942-1050
Mailing Address - Fax:
Practice Address - Street 1:1700 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-5500
Practice Address - Country:US
Practice Address - Phone:312-942-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041290158163W00000X
IL209026137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse