Individual
KELLY J THOMPSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1473 SOUTH ST, FOWLER, IL 62338-2362
(217) 653-3983
Mailing address
1473 SOUTH ST, FOWLER, IL 62338-2362
(217) 653-3983
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
KT LDN 01
IL
Other
Enumeration date
04/24/2008
Last updated
10/20/2009
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