Basic Information
| Provider Information | |||||||||
| NPI: | 1083345359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWAK | ||||||||
| FirstName: | MICHELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25W230 MAYFLOWER AVE | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605403516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586992589 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604358200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157257133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041.430535 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 209.026086 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.