Provider Demographics
NPI:1972182228
Name:KOHLEY, ANNALYSE (MD)
Entity Type:Individual
Prefix:
First Name:ANNALYSE
Middle Name:
Last Name:KOHLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 FEATHERSTONE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6311
Mailing Address - Country:US
Mailing Address - Phone:630-540-6137
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDREN'S WAY
Practice Address - Street 2:SLOT 512-19A
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202
Practice Address - Country:US
Practice Address - Phone:501-364-1874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program