Healthcare Provider Details

I. General information

NPI: 1720798341
Provider Name (Legal Business Name): NATHAN EUGENE KELLENBERGER APRN-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 N GLEN PARK PLACE RD
PEORIA IL
61614-4686
US

IV. Provider business mailing address

5114 N GLEN PARK PLACE RD
PEORIA IL
61614-4686
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2431
  • Fax:
Mailing address:
  • Phone: 309-655-2431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.026515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: