Provider Demographics
NPI:1255681557
Name:FRENCH, KALLIE M (PAC)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:M
Last Name:FRENCH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:M
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-475-5200
Mailing Address - Fax:618-351-4821
Practice Address - Street 1:405 RUSHING DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3730
Practice Address - Country:US
Practice Address - Phone:618-993-3300
Practice Address - Fax:618-997-6626
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification