Individual
KIM FONNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3395 W LAKE PARADISE RD, MATTOON, IL 61938-8969
(217) 234-2327
Mailing address
3395 W LAKE PARADISE RD, MATTOON, IL 61938-8969
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
160-002514
IL
225XP0200X
Pediatric Occupational Therapist
Primary
056008777
IL
Other
Enumeration date
04/14/2007
Last updated
08/28/2017
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