Provider Demographics
NPI:1013602184
Name:THOMPSON, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:THOMPSON
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 1:308 S KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2636
Mailing Address - Country:US
Mailing Address - Phone:309-258-8073
Mailing Address - Fax:
Practice Address - Street 1:2001 W WILLOW KNOLLS DR STE 201
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1261
Practice Address - Country:US
Practice Address - Phone:309-219-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026932363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily