Healthcare Provider Details

I. General information

NPI: 1104287630
Provider Name (Legal Business Name): KRISTINA KAY MERSHON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N BRINTON AVE
DIXON IL
61021-9532
US

IV. Provider business mailing address

2306 BEACH RD
ASHTON IL
61006-9422
US

V. Phone/Fax

Practice location:
  • Phone: 815-288-5561
  • Fax:
Mailing address:
  • Phone: 815-761-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: