Provider Demographics
NPI:1346551090
Name:CONNELL, KIMBERLIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLIE
Other - Middle Name:
Other - Last Name:LIEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2040 OGDEN AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7205
Mailing Address - Country:US
Mailing Address - Phone:630-922-8825
Mailing Address - Fax:630-369-8838
Practice Address - Street 1:2040 OGDEN AVE STE 115
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7205
Practice Address - Country:US
Practice Address - Phone:630-922-8825
Practice Address - Fax:630-369-8838
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILCA4748OtherMEDICARE RAILROAD GROUP PTAN
IL206147247OtherMEDICARE PTAN (INDIVIDUAL)
ILP01398543OtherMEDICARE RAILROAD