Provider Demographics
NPI:1386932028
Name:WHITAKER, KELLY M (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-0303
Mailing Address - Country:US
Mailing Address - Phone:618-792-3586
Mailing Address - Fax:
Practice Address - Street 1:124 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2039
Practice Address - Country:US
Practice Address - Phone:186-402-5572
Practice Address - Fax:636-333-4510
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.000945363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health