Healthcare Provider Details

I. General information

NPI: 1447196183
Provider Name (Legal Business Name): KELLY R WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4662 DOGWOOD CT
DECATUR IL
62526-9326
US

IV. Provider business mailing address

4662 DOGWOOD CT
DECATUR IL
62526-9326
US

V. Phone/Fax

Practice location:
  • Phone: 217-413-7519
  • Fax:
Mailing address:
  • Phone: 217-413-7519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041.370135
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: