Healthcare Provider Details

I. General information

NPI: 1710143367
Provider Name (Legal Business Name): KERI JANE MULLINS APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1366 E 1050TH AVE
OBLONG IL
62449-2409
US

IV. Provider business mailing address

1366 E 1050TH AVE
OBLONG IL
62449-2409
US

V. Phone/Fax

Practice location:
  • Phone: 618-592-3119
  • Fax: 618-546-2602
Mailing address:
  • Phone: 618-592-3119
  • Fax: 618-546-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209007177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: