Provider Demographics
NPI:1306240767
Name:SLADE, KELLY J (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:SLADE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:CRISPIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:176 W MOUND RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1964
Mailing Address - Country:US
Mailing Address - Phone:217-391-8730
Mailing Address - Fax:217-391-8731
Practice Address - Street 1:176 W MOUND RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1964
Practice Address - Country:US
Practice Address - Phone:217-391-8730
Practice Address - Fax:217-391-8731
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner