Healthcare Provider Details

I. General information

NPI: 1598399693
Provider Name (Legal Business Name): KYLE D. KIESEWETTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

1210 N OLD TRAIL RD
EAST PEORIA IL
61611-1212
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4859
  • Fax:
Mailing address:
  • Phone: 309-264-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number209.020932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: