Provider Demographics
NPI:1184295032
Name:MEISNER, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MEISNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:ZYCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 RYAN PKWY
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-4527
Mailing Address - Country:US
Mailing Address - Phone:815-276-0150
Mailing Address - Fax:877-461-6742
Practice Address - Street 1:1340 RYAN PKWY
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-4527
Practice Address - Country:US
Practice Address - Phone:815-276-0150
Practice Address - Fax:877-461-6742
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant