Healthcare Provider Details

I. General information

NPI: 1871722868
Provider Name (Legal Business Name): KELLIE DEWITT PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 S ORANGE STREET
EL PASO IL
71738
US

IV. Provider business mailing address

385 S ORANGE ST
EL PASO IL
61738-1613
US

V. Phone/Fax

Practice location:
  • Phone: 309-527-4900
  • Fax: 309-527-3525
Mailing address:
  • Phone: 309-527-4900
  • Fax: 309-527-3525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003478
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: