Healthcare Provider Details

I. General information

NPI: 1679327266
Provider Name (Legal Business Name): KENNETH LYLE HOLLAND APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 S 18TH AVE
BROADVIEW IL
60155-3927
US

IV. Provider business mailing address

2325 S 18TH AVE
BROADVIEW IL
60155-3927
US

V. Phone/Fax

Practice location:
  • Phone: 773-706-5802
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number041448188
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209029961
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: