Provider Demographics
NPI:1922385731
Name:FANE, KATELIN (PT)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:
Last Name:FANE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1258
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1275 N. COVENT STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-8210
Practice Address - Country:US
Practice Address - Phone:815-936-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01061411OtherMEDICARE RAILROAD
IL070018860OtherLICENSE
IL216859216Medicare PIN
IL202845225Medicare PIN
IL209812023Medicare PIN