Healthcare Provider Details

I. General information

NPI: 1154146892
Provider Name (Legal Business Name): KAYSHA SIMPSON HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S PROSPECT RD STE 14
BLOOMINGTON IL
61704-4910
US

IV. Provider business mailing address

211 S PROSPECT RD STE 14
BLOOMINGTON IL
61704-4910
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-4312
  • Fax:
Mailing address:
  • Phone: 309-451-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3541
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: