Healthcare Provider Details

I. General information

NPI: 1407170798
Provider Name (Legal Business Name): KELLI RAE DESPLINTER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16142 E 2600 ST
ANNAWAN IL
61234
US

IV. Provider business mailing address

16142 E 2600TH ST
ANNAWAN IL
61234-9533
US

V. Phone/Fax

Practice location:
  • Phone: 309-540-9278
  • Fax:
Mailing address:
  • Phone: 309-540-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.004749
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: