Healthcare Provider Details

I. General information

NPI: 1568430379
Provider Name (Legal Business Name): KATHY MARREN GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 WINDSOR RD
CHAMPAIGN IL
61822-6217
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-5434
  • Fax: 217-366-6106
Mailing address:
  • Phone: 217-366-1326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number083575
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number041362173
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: