Provider Demographics
NPI:1639708688
Name:MCGRATH, KIRSTIE ALI
Entity Type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:ALI
Last Name:MCGRATH
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 1:6 HAIRPIN DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-1000
Mailing Address - Country:US
Mailing Address - Phone:618-650-3956
Mailing Address - Fax:618-650-3854
Practice Address - Street 1:6 HAIRPIN DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-1000
Practice Address - Country:US
Practice Address - Phone:618-650-3956
Practice Address - Fax:618-650-3854
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL390200000X390200000X
IL209021435363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program