Healthcare Provider Details

I. General information

NPI: 1144854373
Provider Name (Legal Business Name): KRISTA ROSE BARTON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTA ROSE TAYLOR

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 N KINZIE AVE
BRADLEY IL
60915-1233
US

IV. Provider business mailing address

990 N KINZIE AVE
BRADLEY IL
60915-1233
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-2589
  • Fax: 815-634-5253
Mailing address:
  • Phone: 815-933-2589
  • Fax: 815-634-5253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041385652
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021125
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: