=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023618667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN RENNELS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2020
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2250 LINCOLN AVE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61920-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-345-9458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10275 E NORTH SHORE DR
-----------------------------------------------------
City | EFFINGHAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62401-7758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-690-5226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.295922
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------