Healthcare Provider Details

I. General information

NPI: 1902259542
Provider Name (Legal Business Name): KELLY NICHOLE ECKHART APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ECKHART RN

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W GRAND AVE
LAKE VILLA IL
60046-8034
US

IV. Provider business mailing address

23870 W TOWNLINE RD
GRAYSLAKE IL
60030-9764
US

V. Phone/Fax

Practice location:
  • Phone: 847-245-6262
  • Fax: 847-356-0364
Mailing address:
  • Phone: 847-609-5760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.034966
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: