Healthcare Provider Details

I. General information

NPI: 1336638279
Provider Name (Legal Business Name): KEANLYNN M MCWILLIAMS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7180 SPRING BROOK RD
ROCKFORD IL
61114-6700
US

IV. Provider business mailing address

PO BOX 1567
ROCKFORD IL
61110-0067
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-2750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209-017726
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-399775
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: