Individual
KENDRA MICKELSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
700 N MAIN ST, EUREKA, IL 61530-1085
(309) 467-9094
(309) 467-9011
Mailing address
700 N MAIN ST, EUREKA, IL 61530-1085
(309) 467-9094
(309) 467-9011
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
0042424
IL
314000000X
Skilled Nursing Facility
1694647
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0042424
—
IL
01
—
314000000X
TAXONOMY NUMBER
IL
Enumeration date
07/20/2016
Last updated
07/20/2016
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