Provider Demographics
NPI:1104464767
Name:STONE, KELLY
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:STONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 WINDSOR RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4276
Mailing Address - Country:US
Mailing Address - Phone:815-986-1113
Mailing Address - Fax:
Practice Address - Street 1:1752 WINDSOR RD STE 203
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4276
Practice Address - Country:US
Practice Address - Phone:815-986-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1104464767363LP0808X
IL209.020616363LP0808X
IL277.001677363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL277.001677OtherLICENSE NUMBER