Healthcare Provider Details

I. General information

NPI: 1316635220
Provider Name (Legal Business Name): KELLY BLANCHE ALLEN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 W COLLEGE DR STE 102
PALOS HEIGHTS IL
60463-1181
US

IV. Provider business mailing address

1427 CHAMPLAIN ST
OTTAWA IL
61350-2403
US

V. Phone/Fax

Practice location:
  • Phone: 708-840-3733
  • Fax:
Mailing address:
  • Phone: 219-921-6844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209027148
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: