Healthcare Provider Details

I. General information

NPI: 1417503988
Provider Name (Legal Business Name): HOLLY ELIZABETH KELSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 N MORTON AVE
MORTON IL
61550-1426
US

IV. Provider business mailing address

2510 N WILSON DR
PEORIA IL
61604-2465
US

V. Phone/Fax

Practice location:
  • Phone: 309-263-9124
  • Fax:
Mailing address:
  • Phone: 309-242-0739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209019726
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209019726
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: