Provider Demographics
NPI:1740524743
Name:KRUGER, KELLY ANN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:KRUGER
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 1:6605 S KINSMAN RD
Mailing Address - Street 2:PO BOX 781
Mailing Address - City:KINSMAN
Mailing Address - State:IL
Mailing Address - Zip Code:60437-4027
Mailing Address - Country:US
Mailing Address - Phone:815-791-3996
Mailing Address - Fax:
Practice Address - Street 1:6605 S KINSMAN RD
Practice Address - Street 2:
Practice Address - City:KINSMAN
Practice Address - State:IL
Practice Address - Zip Code:60437-4027
Practice Address - Country:US
Practice Address - Phone:815-791-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILK626-5017-8863347C00000X
ILK626-5197-8080347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle