Healthcare Provider Details

I. General information

NPI: 1891136313
Provider Name (Legal Business Name): REBECCA KILLIAN EDMONDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 N ATCHISON AVE STE B
MARION IL
62959-5426
US

IV. Provider business mailing address

1306 N ATCHISON AVE STE B
MARION IL
62959-5426
US

V. Phone/Fax

Practice location:
  • Phone: 618-988-6000
  • Fax: 618-942-7111
Mailing address:
  • Phone: 618-988-6000
  • Fax: 618-942-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004711
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: