Individual
KELLY M WHITAKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
124 W MAIN ST, MASCOUTAH, IL 62258-2039
(186) 402-5572
(636) 333-4510
Mailing address
PO BOX 303, MASCOUTAH, IL 62258-0303
(618) 792-3586
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
277.000945
IL
Other
Enumeration date
07/15/2011
Last updated
11/19/2024
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