Provider Demographics
NPI:1992158356
Name:MICKELSON, KENDRA
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:MICKELSON
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 1:700 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1085
Mailing Address - Country:US
Mailing Address - Phone:309-467-9094
Mailing Address - Fax:309-467-9011
Practice Address - Street 1:700 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1085
Practice Address - Country:US
Practice Address - Phone:309-467-9094
Practice Address - Fax:309-467-9011
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0042424314000000X
IL1694647314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0042424Medicaid
IL314000000XOtherTAXONOMY NUMBER
IL145431Medicare PIN
IL145431Medicare UPIN
IL314000000XOtherTAXONOMY NUMBER