Provider Demographics
NPI:1487054425
Name:ENDRESS, KATHRYN M (NP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:ENDRESS
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 1:1701 W GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-3531
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-680-7686
Practice Address - Street 1:1701 W GARDEN ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-3531
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-680-7686
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-011751363L00000X
ILF06141327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-011751OtherIL LICENSE
IL309-007528OtherIL CONTROLLED SUBSTANCE LICENSE