Healthcare Provider Details

I. General information

NPI: 1598362980
Provider Name (Legal Business Name): COURTNEY KLEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 N. BERKLEY AVE
PEORIA IL
61603
US

IV. Provider business mailing address

1628 KINGSBURY RD
WASHINGTON IL
61571-9261
US

V. Phone/Fax

Practice location:
  • Phone: 309-886-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022155
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: