Healthcare Provider Details

I. General information

NPI: 1992494595
Provider Name (Legal Business Name): KACIE DANIELLE ZIELSDORF PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 W CHURCH ST
CHAMPAIGN IL
61820-3320
US

IV. Provider business mailing address

PO BOX 63
ARROWSMITH IL
61722-0063
US

V. Phone/Fax

Practice location:
  • Phone: 217-373-1700
  • Fax:
Mailing address:
  • Phone: 309-706-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209027337
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: