Healthcare Provider Details

I. General information

NPI: 1619063187
Provider Name (Legal Business Name): KELLY L GALBRAITH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLENE LYNN GALBRAITH RN

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W CHESTNUT ST
BLOOMINGTON IL
61701-2814
US

IV. Provider business mailing address

702 W CHESTNUT ST
BLOOMINGTON IL
61701-2814
US

V. Phone/Fax

Practice location:
  • Phone: 309-557-1400
  • Fax: 309-557-1461
Mailing address:
  • Phone: 309-557-1400
  • Fax: 309-557-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-000546
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number309.000186
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: