Healthcare Provider Details

I. General information

NPI: 1902571235
Provider Name (Legal Business Name): JUSTYNA ANNA KOSCIELNIAK APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUSTYNA ANNA GANO

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST STE 200
PEORIA IL
61606-2035
US

IV. Provider business mailing address

2015 TRACY DR APT 3
BLOOMINGTON IL
61704-7523
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5682
  • Fax: 309-672-3147
Mailing address:
  • Phone: 619-779-1392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number277004369
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209.023771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: