Provider Demographics
NPI:1649160359
Name:GOLDSBY, KALLINA MARIE
Entity type:Individual
Prefix:
First Name:KALLINA
Middle Name:MARIE
Last Name:GOLDSBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19120 134TH AVE W
Mailing Address - Street 2:
Mailing Address - City:TAYLOR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61284-9100
Mailing Address - Country:US
Mailing Address - Phone:309-269-5185
Mailing Address - Fax:
Practice Address - Street 1:19120 134TH AVE W
Practice Address - Street 2:
Practice Address - City:TAYLOR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:61284-9100
Practice Address - Country:US
Practice Address - Phone:309-269-5185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG185308363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health