Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036133961 | IL |
NPI | 1003136276 |
---|---|
Provider Name | Dr. Kaitlin Delaney Henry |
First Address | Springfield, IL 62703-2403 |
Second Address | Springfield, IL 62704 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2010 |
Last Update Date | 22/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036133961 | IDFPR (01) | IL |