Provider Demographics
NPI:1942603907
Name:MARSAGLIA, KILEY NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:NICOLE
Last Name:MARSAGLIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 WIND MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-9730
Mailing Address - Country:US
Mailing Address - Phone:217-891-7061
Mailing Address - Fax:
Practice Address - Street 1:620 WIND MEADOW DR
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-9730
Practice Address - Country:US
Practice Address - Phone:217-891-7061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000954363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical