Provider Demographics
NPI:1497983928
Name:KELEHER, NOREEN B (PA-C)
Entity Type:Individual
Prefix:
First Name:NOREEN
Middle Name:B
Last Name:KELEHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NOREEN
Other - Middle Name:B
Other - Last Name:CONNIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2320 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2426
Mailing Address - Country:US
Mailing Address - Phone:708-388-5500
Mailing Address - Fax:708-226-7174
Practice Address - Street 1:2320 HIGH ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2426
Practice Address - Country:US
Practice Address - Phone:708-388-5500
Practice Address - Fax:708-226-7174
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL964290009Medicare PIN