Healthcare Provider Details

I. General information

NPI: 1124093927
Provider Name (Legal Business Name): PATTI LYNN ALLY MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE SUITE 116
PEORIA IL
61614-5021
US

IV. Provider business mailing address

6 VICTORY DR
LIBERTY MO
64068-3807
US

V. Phone/Fax

Practice location:
  • Phone: 309-282-0887
  • Fax: 309-282-0947
Mailing address:
  • Phone: 816-313-2800
  • Fax: 816-792-9819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number147000515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: