Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 209.011300 | IL |
NPI | 1003232489 |
---|---|
Provider Name | Melissa G Kulp |
First Address | Carrollton, IL 62016-1436 |
Second Address | Carrollton, IL 62016-1436 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2014 |
Last Update Date | 10/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
209011300 | ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION (01) | IL |