Healthcare Provider Details

I. General information

NPI: 1992158356
Provider Name (Legal Business Name): KENDRA MICKELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N MAIN ST
EUREKA IL
61530-1085
US

IV. Provider business mailing address

700 N MAIN ST
EUREKA IL
61530-1085
US

V. Phone/Fax

Practice location:
  • Phone: 309-467-9094
  • Fax: 309-467-9011
Mailing address:
  • Phone: 309-467-9094
  • Fax: 309-467-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0042424
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1694647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: