Provider Demographics
NPI:1124792288
Name:CARLSON, KELCY MARIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELCY
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 ILLINOIS ROUTE 15
Mailing Address - Street 2:
Mailing Address - City:ELLERY
Mailing Address - State:IL
Mailing Address - Zip Code:62833-4409
Mailing Address - Country:US
Mailing Address - Phone:618-302-3199
Mailing Address - Fax:
Practice Address - Street 1:363 N WEST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-1160
Practice Address - Country:US
Practice Address - Phone:618-392-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023657363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health