1053753582 NPI number — KATHLEEN L KRETCHMER R.N., C.D.E

Table of content: KATHLEEN L KRETCHMER R.N., C.D.E (NPI 1053753582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053753582 NPI number — KATHLEEN L KRETCHMER R.N., C.D.E

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRETCHMER
Provider First Name:
KATHLEEN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.N., C.D.E
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053753582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 STATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-7978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-338-6600
Provider Business Mailing Address Fax Number:
815-356-2388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 STATION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-7978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-338-6600
Provider Business Practice Location Address Fax Number:
815-356-2388
Provider Enumeration Date:
07/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , with the licence number:  041304879 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 962341 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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