Provider Demographics
NPI:1952588956
Name:WILKERSON DULLENTY, KELLY REBEKAH (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:REBEKAH
Last Name:WILKERSON DULLENTY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1210 TOWANDA PLZ
Mailing Address - Street 2:#17
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3454
Mailing Address - Country:US
Mailing Address - Phone:309-828-6200
Mailing Address - Fax:309-828-6002
Practice Address - Street 1:1210 TOWANDA PLZ
Practice Address - Street 2:#17
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3454
Practice Address - Country:US
Practice Address - Phone:309-828-6200
Practice Address - Fax:309-828-6002
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011098111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732071OtherBCBS OF ILLINOIS
IL5732071OtherBCBS OF ILLINOIS