Provider Demographics
NPI:1265543557
Name:BLILER, KATHI LYNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATHI
Middle Name:LYNE
Last Name:BLILER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATHI
Other - Middle Name:LYNE
Other - Last Name:KETTERLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:650 DAKOTA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3744
Mailing Address - Country:US
Mailing Address - Phone:815-455-6000
Mailing Address - Fax:815-356-1104
Practice Address - Street 1:650 DAKOTA ST
Practice Address - Street 2:SUITE A
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3744
Practice Address - Country:US
Practice Address - Phone:815-455-6000
Practice Address - Fax:815-356-1104
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP37316Medicare UPIN