Healthcare Provider Details

I. General information

NPI: 1831019264
Provider Name (Legal Business Name): KELLY LEE WHITESIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W EGGLESTON AVE
ELMHURST IL
60126-3889
US

IV. Provider business mailing address

501 S BERKLEY AVE
ELMHURST IL
60126-3728
US

V. Phone/Fax

Practice location:
  • Phone: 312-493-1021
  • Fax:
Mailing address:
  • Phone: 312-493-1021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198-000545
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: