Healthcare Provider Details

I. General information

NPI: 1417805409
Provider Name (Legal Business Name): KACEY WOULFE CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 MADISON AVE
GRANITE CITY IL
62040-4700
US

IV. Provider business mailing address

2166 MADISON AVE
GRANITE CITY IL
62040-4700
US

V. Phone/Fax

Practice location:
  • Phone: 618-452-3301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.034987
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: