Healthcare Provider Details

I. General information

NPI: 1366806838
Provider Name (Legal Business Name): KILEY M FAIRES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DRIVE STE 360
BELLEVILLE IL
62226
US

IV. Provider business mailing address

4600 MEMORIAL DRIVE STE 360
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-7280
  • Fax: 618-222-7281
Mailing address:
  • Phone: 618-222-7280
  • Fax: 618-222-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: