Provider Demographics
NPI:1366176612
Name:KINGSTAD, HANNA MARIE
Entity type:Individual
Prefix:
First Name:HANNA
Middle Name:MARIE
Last Name:KINGSTAD
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 1:2650 RIDGE AVE.
Mailing Address - Street 2:WALGREEN 3507
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2827
Mailing Address - Fax:847-733-5005
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:WALGREEN 3507
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2827
Practice Address - Fax:847-733-5005
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085010156363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical