Healthcare Provider Details

I. General information

NPI: 1598993362
Provider Name (Legal Business Name): ELIZABETH ANN KAJENCKI RST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10326 N JULIET CT
PEORIA IL
61615-1199
US

IV. Provider business mailing address

10326 N JULIET CT
PEORIA IL
61615-1199
US

V. Phone/Fax

Practice location:
  • Phone: 309-243-8500
  • Fax: 309-243-8514
Mailing address:
  • Phone: 309-243-8500
  • Fax: 309-243-8514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number237.000053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: