=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245886134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN ELIZABETH KILKENNY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1099 MOUNT HOPE LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63366-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-240-9484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 ALFRESCO DR
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-5518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-616-3443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2019023571
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------