Provider Demographics
NPI:1447223789
Name:MEADE, KATHLEEN M
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MEADE
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 1:9951 ROCK CUT XING
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-1999
Mailing Address - Country:US
Mailing Address - Phone:815-639-8500
Mailing Address - Fax:815-639-8501
Practice Address - Street 1:9951 ROCK CUT XING
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-1999
Practice Address - Country:US
Practice Address - Phone:815-639-8500
Practice Address - Fax:815-639-8501
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000929363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL81495OtherMEDICARE PRIOR 7/15/2007
ILL81495OtherMEDICARE PRIOR 7/15/2007
ILP15060Medicare UPIN
ILK38609Medicare PIN