Healthcare Provider Details

I. General information

NPI: 1417468190
Provider Name (Legal Business Name): KELLI MOWRER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CUSUMANO PROFESSIONAL PLAZA DR
MOUNT VERNON IL
62864-6736
US

IV. Provider business mailing address

8 CUSUMANO PROFESSIONAL PLAZA DR
MOUNT VERNON IL
62864-6736
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-4800
  • Fax: 618-241-1746
Mailing address:
  • Phone: 618-244-4800
  • Fax: 618-241-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209016577
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: