Healthcare Provider Details

I. General information

NPI: 1689393233
Provider Name (Legal Business Name): KELCIE MARLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E CENTRAL AVE
DECATUR IL
62521-4665
US

IV. Provider business mailing address

201 S ADAMS ST
ATHENS IL
62613-9440
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-9117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.025136
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: