Provider Demographics
NPI:1932448396
Name:RANKIN, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RANKIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 ESSINGTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1634
Mailing Address - Country:US
Mailing Address - Phone:815-676-5310
Mailing Address - Fax:815-725-1321
Practice Address - Street 1:2202 ESSINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1634
Practice Address - Country:US
Practice Address - Phone:815-676-5310
Practice Address - Fax:815-725-1321
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004503OtherSTATE LICENSE