Basic Information
Provider Information
NPI: 1407249519
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WEBER
FirstName: KATHLEEN
MiddleName: K
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: RICKERS
OtherFirstName: KATHLEEN
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: RN
OtherLastNameType: 1
Mailing Information
Address1: 287 SONATA CT
Address2:  
City: VOLO
State: IL
PostalCode: 600735901
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3010 GRAND AVE
Address2:  
City: WAUKEGAN
State: IL
PostalCode: 600852321
CountryCode: US
TelephoneNumber: 8473778180
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/13/2015
LastUpdateDate: 03/13/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000X041414096ILY Nursing Service ProvidersRegistered Nurse 

No ID Information.


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