Provider Demographics
NPI:1194120337
Name:POWELL, KATHLEEN (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8012 S CRANDON AVE
Mailing Address - Street 2:RM. 318
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1124
Mailing Address - Country:US
Mailing Address - Phone:773-356-5355
Mailing Address - Fax:773-768-8154
Practice Address - Street 1:8012 S CRANDON AVE
Practice Address - Street 2:RM. 318
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-356-5355
Practice Address - Fax:773-768-8154
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.147476163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214641Medicare PIN