Provider Demographics
NPI:1588164610
Name:KOZLOWSKI, KELLIE MARIE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:MARIE
Last Name:KOZLOWSKI
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MS
Other - First Name:KELLIE
Other - Middle Name:MARIE
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1916 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356
Mailing Address - Country:US
Mailing Address - Phone:815-915-8748
Mailing Address - Fax:815-664-0508
Practice Address - Street 1:1916 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-915-8748
Practice Address - Fax:815-664-0508
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017042363LP0808X
IL209.017042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health