Provider Demographics
NPI:1215561600
Name:KLIEBE, KELLY L
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:KLIEBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:DIEHL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:106 E INDIAN COVE DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-9320
Mailing Address - Country:US
Mailing Address - Phone:815-908-9919
Mailing Address - Fax:
Practice Address - Street 1:325 ILLINOIS RT 2
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9118
Practice Address - Country:US
Practice Address - Phone:815-284-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN197387163WP0808X
IL0141404877163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health