Provider Demographics
NPI:1982187357
Name:DENSON, KAITLIN MARIE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:DENSON
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9261
Practice Address - Country:US
Practice Address - Phone:217-238-4019
Practice Address - Fax:217-238-4336
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-018095163WC2100X, 163WW0000X, 163WX1500X, 363LF0000X
IL209.018095363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner