Healthcare Provider Details

I. General information

NPI: 1063815645
Provider Name (Legal Business Name): KELLY N. CARROLL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 HARLEM RD
LOVES PARK IL
61111-2754
US

IV. Provider business mailing address

2202 HARLEM RD
LOVES PARK IL
61111-2754
US

V. Phone/Fax

Practice location:
  • Phone: 815-877-4848
  • Fax: 815-636-6125
Mailing address:
  • Phone: 815-877-4848
  • Fax: 815-636-6125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.363284
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number172314-30
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.011923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: