Provider Demographics
NPI:1073068375
Name:KENERSON, KILEE
Entity Type:Individual
Prefix:
First Name:KILEE
Middle Name:
Last Name:KENERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N BURBANK AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-5432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 N BURBANK AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-5432
Practice Address - Country:US
Practice Address - Phone:779-210-4824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide