Healthcare Provider Details

I. General information

NPI: 1912366436
Provider Name (Legal Business Name): KACEY PANYIK APN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W STATE ST
O FALLON IL
62269-1913
US

IV. Provider business mailing address

502 W STATE ST
O FALLON IL
62269-1913
US

V. Phone/Fax

Practice location:
  • Phone: 618-417-7148
  • Fax: 904-615-8373
Mailing address:
  • Phone: 618-417-7148
  • Fax: 904-615-8373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209013810
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: