Provider Demographics
NPI:1902236912
Name:KODIAK, TERESA WYATT (APN-CNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:WYATT
Last Name:KODIAK
Suffix:
Gender:F
Credentials:APN-CNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4911
Mailing Address - Country:US
Mailing Address - Phone:773-570-3382
Mailing Address - Fax:
Practice Address - Street 1:611 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4911
Practice Address - Country:US
Practice Address - Phone:773-570-3382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL219010786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily