Healthcare Provider Details

I. General information

NPI: 1518435247
Provider Name (Legal Business Name): DAVIS FAMILY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 MERIDEN ST
MENDOTA IL
61342-2501
US

IV. Provider business mailing address

1201 MERIDEN ST
MENDOTA IL
61342-2501
US

V. Phone/Fax

Practice location:
  • Phone: 815-538-1800
  • Fax: 815-538-4881
Mailing address:
  • Phone: 815-538-1800
  • Fax: 815-538-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY ANN TONIELLI DAVIS
Title or Position: PROVIDER/OWNER FULL PRACTICE AUTHOR
Credential: DNP APRN FNP-BC
Phone: 815-538-1800