Provider Demographics
NPI:1427489772
Name:INGENITO, KALEY (PA-C)
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:
Last Name:INGENITO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2433
Mailing Address - Country:US
Mailing Address - Phone:847-432-8000
Mailing Address - Fax:
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 300
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2772
Practice Address - Country:US
Practice Address - Phone:763-236-9236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant