Healthcare Provider Details

I. General information

NPI: 1770255481
Provider Name (Legal Business Name): ANGELA BROOKE KAYLOR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 FERRELL RD
ROSICLARE IL
62982-1052
US

IV. Provider business mailing address

165 LAMBTOWN RD
CAVE IN ROCK IL
62919-2123
US

V. Phone/Fax

Practice location:
  • Phone: 618-285-6634
  • Fax:
Mailing address:
  • Phone: 618-638-2931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.024116
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: