Provider Demographics
NPI:1699959148
Name:GUILLERGAN-KUPSKI, VIBE PEARL L (APRN-BC)
Entity type:Individual
Prefix:MS
First Name:VIBE PEARL
Middle Name:L
Last Name:GUILLERGAN-KUPSKI
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:VIBE PEARL
Other - Middle Name:L
Other - Last Name:GUILLERGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-BC
Mailing Address - Street 1:90 SONOMA DR
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-5166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-1100
Practice Address - Country:US
Practice Address - Phone:847-673-5166
Practice Address - Fax:847-462-4411
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006841363LA2200X, 363L00000X
IL41286442163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
IL206147095OtherMEDICARE PTAN (INDIVIDUAL)
IL206147095OtherMEDICARE PTAN (INDIVIDUAL)
IL$$$$$$$$$001Medicaid