Healthcare Provider Details

I. General information

NPI: 1467827592
Provider Name (Legal Business Name): KELLY KARR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY AUGSBURGER

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-2100
  • Fax: 309-663-8322
Mailing address:
  • Phone: 309-663-2100
  • Fax: 309-663-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-370455
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-013789
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: