Provider Demographics
NPI:1285004663
Name:VOLLINTINE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:VOLLINTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 HILTON AVENUE
Mailing Address - Street 2:BOX52
Mailing Address - City:PANAMA
Mailing Address - State:IL
Mailing Address - Zip Code:62077
Mailing Address - Country:US
Mailing Address - Phone:217-414-9126
Mailing Address - Fax:
Practice Address - Street 1:315 HILTON AVENUE
Practice Address - Street 2:BOX52
Practice Address - City:PANAMA
Practice Address - State:IL
Practice Address - Zip Code:62077
Practice Address - Country:US
Practice Address - Phone:217-414-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker