Provider Demographics
NPI:1548652720
Name:NELCZYK, KIMBERLY LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LAUREN
Last Name:NELCZYK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KOWALCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23.003285363AM0700X
IL085005725363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical