Healthcare Provider Details

I. General information

NPI: 1063424836
Provider Name (Legal Business Name): NANCY K KERTZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 S WATER TOWER PL SUITE D
MOUNT VERNON IL
62864-6293
US

IV. Provider business mailing address

107 LINCOLN LN
BROOKINGS SD
57006-2634
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-4848
  • Fax: 618-242-4198
Mailing address:
  • Phone: 605-695-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000435
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: