Healthcare Provider Details

I. General information

NPI: 1588164610
Provider Name (Legal Business Name): KELLIE MARIE KOZLOWSKI PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLIE MARIE PHELPS FNP-BC

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 NORTH MAIN STREET
PRINCETON IL
61356
US

IV. Provider business mailing address

1916 NORTH MAIN STREET
PRINCETON IL
61356
US

V. Phone/Fax

Practice location:
  • Phone: 815-915-8748
  • Fax: 815-664-0508
Mailing address:
  • Phone: 815-915-8748
  • Fax: 815-664-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209017042
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017042
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: