Provider Demographics
NPI:1306949375
Name:STOCKER, KATHLEEN GRACE (APRN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
Last Name:STOCKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-6126
Mailing Address - Country:US
Mailing Address - Phone:217-243-6454
Mailing Address - Fax:217-243-1388
Practice Address - Street 1:1745 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-6126
Practice Address - Country:US
Practice Address - Phone:217-243-6454
Practice Address - Fax:217-243-1388
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000579363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370661499007Medicaid
S98066Medicare UPIN
IL14 8920Medicare ID - Type Unspecified