Healthcare Provider Details

I. General information

NPI: 1013303890
Provider Name (Legal Business Name): KRISTINA DAKIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S DIXIE HWY
HOOPESTON IL
60942-1904
US

IV. Provider business mailing address

1120 N MELVIN ST
GIBSON CITY IL
60936-1477
US

V. Phone/Fax

Practice location:
  • Phone: 217-283-5530
  • Fax: 217-283-6437
Mailing address:
  • Phone: 217-283-5530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.146067
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: