Healthcare Provider Details

I. General information

NPI: 1699147215
Provider Name (Legal Business Name): KELLIE BIBB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE SIDENER

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 ATLANTA ST
SPRINGFIELD IL
62707-8801
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-588-2600
  • Fax: 217-862-0202
Mailing address:
  • Phone: 217-588-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013401
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277.000110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: