Healthcare Provider Details

I. General information

NPI: 1629798822
Provider Name (Legal Business Name): KYRA LYN PINEDA GOODELL APRN,CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYRA LYN AUSTRIA APRN,CNP

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 MAXINE DR
MORTON IL
61550-2498
US

IV. Provider business mailing address

4922 N RONALD RD
PEORIA IL
61614-4520
US

V. Phone/Fax

Practice location:
  • Phone: 309-263-2424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041444483
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025830
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.0258230
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041444483
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: