Healthcare Provider Details

I. General information

NPI: 1053684712
Provider Name (Legal Business Name): CHRISTINE LEIGH KMIECIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W LOSEY ST
SCOTT AIR FORCE BASE IL
62225-5250
US

IV. Provider business mailing address

310 W LOSEY ST
SCOTT AIR FORCE BASE IL
62225-5250
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-9355
  • Fax:
Mailing address:
  • Phone: 618-256-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: