Healthcare Provider Details

I. General information

NPI: 1447744438
Provider Name (Legal Business Name): KELSEY MARIE LEVAULT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 BURNETT DR
TAYLORVILLE IL
62568-9519
US

IV. Provider business mailing address

1304 BURNETT DR
TAYLORVILLE IL
62568-9519
US

V. Phone/Fax

Practice location:
  • Phone: 217-321-9310
  • Fax: 217-692-2422
Mailing address:
  • Phone: 217-321-9310
  • Fax: 217-692-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125072817
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: