Basic Information
Provider Information | |||||||||
NPI: | 1265543557 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLILER | ||||||||
FirstName: | KATHI | ||||||||
MiddleName: | LYNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KETTERLING | ||||||||
OtherFirstName: | KATHI | ||||||||
OtherMiddleName: | LYNE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 650 DAKOTA ST | ||||||||
Address2: | SUITE A | ||||||||
City: | CRYSTAL LAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600123744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154556000 | ||||||||
FaxNumber: | 8153561104 | ||||||||
Practice Location | |||||||||
Address1: | 650 DAKOTA ST | ||||||||
Address2: | SUITE A | ||||||||
City: | CRYSTAL LAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600123744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154556000 | ||||||||
FaxNumber: | 8153561104 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 04/27/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-000454 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.