Basic Information
| Provider Information | |||||||||
| NPI: | 1700254703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAMBA | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4440 W 95TH ST STE 6409 | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086100716 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4440 W 95TH ST STE 6409 | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776844327 | ||||||||
| FaxNumber: | 7085201875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 01/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.013207 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1700254703 | 05 | IL | MEDICAID |