Healthcare Provider Details

I. General information

NPI: 1477959724
Provider Name (Legal Business Name): KRISTEN C ERICKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN C SAMUELS

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON ROAD
CHAMPAIGN IL
61820
US

IV. Provider business mailing address

819 BLOOMINGTON ROAD
CHAMPAIGN IL
61820
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax: 217-356-8529
Mailing address:
  • Phone: 217-356-1558
  • Fax: 217-356-8529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-011627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: