Basic Information
| Provider Information | |||||||||
| NPI: | 1740337237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERREN | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENRY | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Practice Location | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085002634 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 080129117 | 01 | IL | RAILROAD MEDICARE | OTHER | 174143 | 01 | IL | HEALTHLINK | OTHER | 10019630 | 01 | IL | BLUE CROSS | OTHER | E26544 | 01 | IL | UPIN | OTHER | 143870 | 05 | IL | MEDICAID | 043448 | 01 | IL | HEALTH ALLIANCE | OTHER |