Provider Demographics
NPI:1598362980
Name:KLEIN, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KLEIN
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 1:1628 KINGSBURY RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1306 N. BERKLEY AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-886-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily