1801095963 NPI number — MRS. KELLY LYNN CUFFE RD, LD, CDE

Table of content: MRS. KELLY LYNN CUFFE RD, LD, CDE (NPI 1801095963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801095963 NPI number — MRS. KELLY LYNN CUFFE RD, LD, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUFFE
Provider First Name:
KELLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POWELL
Provider Other First Name:
KELLY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801095963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 FITNESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOURBONNAIS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60914-9584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-936-6515
Provider Business Mailing Address Fax Number:
815-936-6517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 N WALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-2901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-936-6515
Provider Business Practice Location Address Fax Number:
815-936-6517
Provider Enumeration Date:
07/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  164.003315 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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