Healthcare Provider Details

I. General information

NPI: 1568841872
Provider Name (Legal Business Name): KRISTY LEIGH ILGEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SHORT DR
BLAIRSVILLE PA
15717-8095
US

IV. Provider business mailing address

501 HOWARD AVE SUITE F4
ALTOONA PA
16601-4810
US

V. Phone/Fax

Practice location:
  • Phone: 724-235-7793
  • Fax: 724-675-8668
Mailing address:
  • Phone: 814-889-2020
  • Fax: 814-889-2213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS019539
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: