Active NPI
Kim Fonner
- Pediatric Occupational Therapist
- Mattoon, IL
National Provider Identifier
1174748354
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Occupational Therapist
- License
- 056008777
- Practice address
- 3395 W Lake Paradise Rd
Mattoon, IL 61938-8969 - Phone
- (217) 234-2327
- NPI assigned
- Apr 14, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 160-002514 | IL | |
| Pediatric Occupational Therapist | 225XP0200X | 056008777 | IL | Primary |
Addresses
Primary practice location
3395 W Lake Paradise Rd
Mattoon, IL 61938-8969
Mailing address
3395 W Lake Paradise Rd
Mattoon, IL 61938-8969
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 160-002514 | IL | MD | Physical Therapy Assistant |
| 056008777 | IL | MD | Pediatric Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176508800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1503878400000",
"number": "1174748354",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3395 W LAKE PARADISE RD",
"city": "MATTOON",
"state": "IL",
"postal_code": "619388969"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3395 W LAKE PARADISE RD",
"city": "MATTOON",
"state": "IL",
"postal_code": "619388969",
"telephone_number": "217-234-2327"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FONNER",
"first_name": "KIM",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-04-14",
"last_updated": "2017-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "IL",
"license": "160-002514",
"primary": false
},
{
"code": "225XP0200X",
"taxonomy_group": "",
"desc": "Occupational Therapist, Pediatrics",
"state": "IL",
"license": "056008777",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mattoon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.