Provider Demographics
NPI:1831680057
Name:HARRIS, KELSIE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:HARRIS
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 1:202 W LORTON ST
Mailing Address - Street 2:
Mailing Address - City:ROODHOUSE
Mailing Address - State:IL
Mailing Address - Zip Code:62082-1514
Mailing Address - Country:US
Mailing Address - Phone:217-408-8598
Mailing Address - Fax:
Practice Address - Street 1:202 W LORTON ST
Practice Address - Street 2:
Practice Address - City:ROODHOUSE
Practice Address - State:IL
Practice Address - Zip Code:62082-1514
Practice Address - Country:US
Practice Address - Phone:217-408-8598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide