Healthcare Provider Details

I. General information

NPI: 1629644836
Provider Name (Legal Business Name): KRISTENE MYCHELLE FLANAGAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST STE 500A
PEORIA IL
61606-2038
US

IV. Provider business mailing address

1001 MAIN ST STE 500A
PEORIA IL
61606-2038
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4980
  • Fax:
Mailing address:
  • Phone: 309-696-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.022864
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: