Healthcare Provider Details

I. General information

NPI: 1043175441
Provider Name (Legal Business Name): KELSEY FAUSEL PHARMD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104-2315
US

IV. Provider business mailing address

7859 CANNELLWOOD DR
SOUTH BELOIT IL
61080-9595
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License Number051307343
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License Number2278640
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: