Provider Demographics
NPI:1780753756
Name:CHULLEN, KELLY DAWN (DC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DAWN
Last Name:CHULLEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E HERRIN ST
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3163
Mailing Address - Country:US
Mailing Address - Phone:618-988-9830
Mailing Address - Fax:618-988-9830
Practice Address - Street 1:120 E HERRIN ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3163
Practice Address - Country:US
Practice Address - Phone:618-988-9830
Practice Address - Fax:618-988-9830
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010250111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2832012OtherBCBS
IL038010250Medicaid
IL038010250Medicaid
V03147Medicare UPIN