Provider Demographics
NPI:1962744797
Name:AVANTS, KELSIE LYNN
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:LYNN
Last Name:AVANTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSIE
Other - Middle Name:LYNN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:840 S. WOOD STREET
Mailing Address - Street 2:1424S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-413-3803
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036144025207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine