Healthcare Provider Details

I. General information

NPI: 1487209045
Provider Name (Legal Business Name): CHRISTY ANNE KAY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 STATE ROUTE 162 STE 102
MARYVILLE IL
62062-8560
US

IV. Provider business mailing address

6810 STATE ROUTE 162 STE 102
MARYVILLE IL
62062-8560
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-4076
  • Fax:
Mailing address:
  • Phone: 618-288-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209023042
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2019025808
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2019025808
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209023042
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: