Provider Demographics
NPI:1316635220
Name:ALLEN, KELLY BLANCHE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BLANCHE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 CHAMPLAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2403
Mailing Address - Country:US
Mailing Address - Phone:219-921-6844
Mailing Address - Fax:
Practice Address - Street 1:250 WATER STONE CIR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8313
Practice Address - Country:US
Practice Address - Phone:815-740-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily