Provider Demographics
NPI:1386083061
Name:VOTH, KELLY DANAE (AGNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DANAE
Last Name:VOTH
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 N WILTON AVE
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7999
Mailing Address - Country:US
Mailing Address - Phone:620-200-1086
Mailing Address - Fax:
Practice Address - Street 1:2614 N WILTON AVE
Practice Address - Street 2:#1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7999
Practice Address - Country:US
Practice Address - Phone:620-200-1086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010428363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health