Provider Demographics
NPI:1306010913
Name:KELLIM, KRISTIN NICOLE (MPT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:KELLIM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-651-0444
Mailing Address - Fax:618-654-5439
Practice Address - Street 1:1138 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095
Practice Address - Country:US
Practice Address - Phone:618-259-1100
Practice Address - Fax:618-259-1101
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010372174400000X
IL070.017045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1793001Medicare UPIN
MO000014766Medicare PIN