Healthcare Provider Details

I. General information

NPI: 1700799822
Provider Name (Legal Business Name): KAITLYN BOCKELMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-1000
US

IV. Provider business mailing address

1800 BRANTON CT
BROADVIEW HEIGHTS OH
44147-4409
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 440-724-9045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.012542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: