Provider Demographics
NPI:1659140796
Name:RUSSELL, KATELIN LEE ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KATELIN
Middle Name:LEE ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KATELIN
Other - Middle Name:LEE ANN
Other - Last Name:BOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 EMERALD TER
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2321
Mailing Address - Country:US
Mailing Address - Phone:618-234-6000
Mailing Address - Fax:
Practice Address - Street 1:18 EMERALD TER
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2321
Practice Address - Country:US
Practice Address - Phone:618-234-6000
Practice Address - Fax:618-234-6009
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.014099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor