Provider Demographics
NPI:1417705534
Name:DUCKWITZ, KEIDRON NICOLE (RN)
Entity type:Individual
Prefix:
First Name:KEIDRON
Middle Name:NICOLE
Last Name:DUCKWITZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4066 N 500TH ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:IL
Mailing Address - Zip Code:62443-2517
Mailing Address - Country:US
Mailing Address - Phone:217-663-4305
Mailing Address - Fax:
Practice Address - Street 1:1 HAIRPIN DRIVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-0001
Practice Address - Country:US
Practice Address - Phone:618-650-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program