Healthcare Provider Details

I. General information

NPI: 1194113514
Provider Name (Legal Business Name): BRENN KILLION PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W BRIDGEPORT ST
WHITE HALL IL
62092-1001
US

IV. Provider business mailing address

427 N STATE ST
ROODHOUSE IL
62082-1066
US

V. Phone/Fax

Practice location:
  • Phone: 217-374-2144
  • Fax:
Mailing address:
  • Phone: 217-370-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number070012647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: