Provider Demographics
NPI:1346781879
Name:VAIDYA, KELLIE (APN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:VAIDYA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1533
Mailing Address - Country:US
Mailing Address - Phone:708-207-2300
Mailing Address - Fax:
Practice Address - Street 1:999 OAKMONT PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1381
Practice Address - Country:US
Practice Address - Phone:630-850-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041325823163W00000X
IL209016357363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner