Provider Demographics
NPI:1194113514
Name:KILLION, BRENN (PT)
Entity type:Individual
Prefix:
First Name:BRENN
Middle Name:
Last Name:KILLION
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROODHOUSE
Mailing Address - State:IL
Mailing Address - Zip Code:62082-1066
Mailing Address - Country:US
Mailing Address - Phone:217-370-0230
Mailing Address - Fax:
Practice Address - Street 1:620 W BRIDGEPORT ST
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:IL
Practice Address - Zip Code:62092-1001
Practice Address - Country:US
Practice Address - Phone:217-374-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist