Provider Demographics
NPI:1063909299
Name:PERISIN, KELLY L (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:PERISIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:KALKOFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2608 W SESAME ST
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-7527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2426 W CORNERSTONE CT STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2400
Practice Address - Country:US
Practice Address - Phone:309-966-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017367363L00000X
MO2018012099363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily