Healthcare Provider Details

I. General information

NPI: 1518805753
Provider Name (Legal Business Name): NINA ROSE KOBOLON-NGAUSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2026
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 W RACHAEL CT
PEORIA IL
61615-3062
US

IV. Provider business mailing address

5710 W RACHAEL CT
PEORIA IL
61615-3062
US

V. Phone/Fax

Practice location:
  • Phone: 717-802-4493
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number041.589014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: