Healthcare Provider Details

I. General information

NPI: 1679285183
Provider Name (Legal Business Name): KELSEY MORGAN RIEKENA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 SHERWOOD DR
LAKE BLUFF IL
60044-2224
US

IV. Provider business mailing address

917 SHERWOOD DR
LAKE BLUFF IL
60044-2224
US

V. Phone/Fax

Practice location:
  • Phone: 847-295-1220
  • Fax:
Mailing address:
  • Phone: 847-295-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042.620722
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: