Basic Information
| Provider Information | |||||||||
| NPI: | 1144545237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIENIA | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | LACCI | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C, MMSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2545 S KING DR | ||||||||
| Address2: | SYKES ADVOCATE MEDICAL GROUP | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128427117 | ||||||||
| FaxNumber: | 3128083383 | ||||||||
| Practice Location | |||||||||
| Address1: | 2545 S KING DR | ||||||||
| Address2: | SYKES ADVOCATE MEDICAL GROUP | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128427117 | ||||||||
| FaxNumber: | 3128083383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085-003678 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 085003678 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085-003678 | 01 | IL | STATE LICENSE | OTHER |