Provider Demographics
NPI:1871722868
Name:DEWITT, KELLIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:IL
Mailing Address - Zip Code:61738-1613
Mailing Address - Country:US
Mailing Address - Phone:309-527-4900
Mailing Address - Fax:309-527-3525
Practice Address - Street 1:385 S ORANGE STREET
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:IL
Practice Address - Zip Code:71738
Practice Address - Country:US
Practice Address - Phone:309-527-4900
Practice Address - Fax:309-527-3525
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant