Provider Demographics
NPI:1649016528
Name:RODRIGUEZ, KESSIE (PA)
Entity type:Individual
Prefix:MISS
First Name:KESSIE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KESSIE
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-1248
Mailing Address - Fax:
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3981
Practice Address - Country:US
Practice Address - Phone:217-366-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085010689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant