Provider Demographics
NPI:1063424836
Name:KERTZ, NANCY K (NP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:K
Last Name:KERTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 LINCOLN LN
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2634
Mailing Address - Country:US
Mailing Address - Phone:605-695-5565
Mailing Address - Fax:
Practice Address - Street 1:4117 S WATER TOWER PL
Practice Address - Street 2:SUITE D
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:618-242-4848
Practice Address - Fax:618-242-4198
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000435363LF0000X
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS101644Medicare PIN