Provider Demographics
NPI:1134396211
Name:SUPPLE, KATHY G
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:G
Last Name:SUPPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2434 WOLF RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5634
Practice Address - Country:US
Practice Address - Phone:708-562-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003663363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care