MEDICARE: KELLIE BIBB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209013401	IL
2	363LF0000X	Family Nurse Practitioner	277.000110	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041.382679	OTHER	IL	RN

General Provider Information

NPI Number	:	1699147215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE BIBB

Provider Business Mailing Address
First Line	:	PO BOX 3428
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62708-3428
Country	:	US
Telephone Number	:	217-588-2600
Fax Number	:

Provider Business Practice Location Address
First Line	:	3220 ATLANTA ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-8801
Country	:	US
Telephone Number	:	217-588-2600
Fax Number	:	217-862-0202

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2015
Last Update Date	:	07/19/2022

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