Healthcare Provider Details

I. General information

NPI: 1689245656
Provider Name (Legal Business Name): KELSEY KAY PARK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

IV. Provider business mailing address

10551 E 680TH AVE
ROBINSON IL
62454-6367
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3131
  • Fax:
Mailing address:
  • Phone: 309-202-1898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209023556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: