Provider Demographics
NPI:1528259389
Name:NILES, KATHLEEN O'SULLIVAN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:O'SULLIVAN
Last Name:NILES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:O'SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:14110 STONEGATE LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-7602
Mailing Address - Country:US
Mailing Address - Phone:708-403-9633
Mailing Address - Fax:
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-747-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered