Provider Demographics
NPI:1457658304
Name:FLETCHER, KIMBERLY CONN (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:CONN
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 S WAUKEGAN RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2608
Mailing Address - Country:US
Mailing Address - Phone:224-544-5033
Mailing Address - Fax:
Practice Address - Street 1:840 S WAUKEGAN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2608
Practice Address - Country:US
Practice Address - Phone:224-544-5033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4720012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038011833OtherILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION
WI4720012OtherWISCONSIN DEPARTMENT OF REGULATION AND LICENSING