Healthcare Provider Details

I. General information

NPI: 1841027083
Provider Name (Legal Business Name): KELLY CHRISTINE PUENT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST
PEORIA IL
61606-1907
US

IV. Provider business mailing address

705 CRESTVIEW DR
WASHINGTON IL
61571-1604
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 309-713-6702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209-030609
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209-030609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: