Provider Demographics
NPI:1386304764
Name:MEYER, KELSEY (NP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MEYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 E MCCORD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3610
Mailing Address - Country:US
Mailing Address - Phone:618-899-9200
Mailing Address - Fax:
Practice Address - Street 1:1297 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-1718
Practice Address - Country:US
Practice Address - Phone:618-227-7229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty