Healthcare Provider Details

I. General information

NPI: 1922762798
Provider Name (Legal Business Name): CARRIE JEAN KOGER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MADISON ST
SPRINGFIELD IL
62701-1035
US

IV. Provider business mailing address

6630 COOLIDGE DR
CANTRALL IL
62625-8885
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3948
  • Fax:
Mailing address:
  • Phone: 217-971-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.024242
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.394318
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: