Basic Information
| Provider Information | |||||||||
| NPI: | 1316592256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUNG | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 N WINFIELD RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 N WINFIELD RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.018725 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209018725 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.