Provider Demographics
NPI:1558957845
Name:WOLLERMAN, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WOLLERMAN
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 1:1220 E TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-1955
Mailing Address - Country:US
Mailing Address - Phone:217-532-4351
Mailing Address - Fax:217-532-4350
Practice Address - Street 1:1220 E TREMONT ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1955
Practice Address - Country:US
Practice Address - Phone:217-532-4351
Practice Address - Fax:217-532-4350
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty