Healthcare Provider Details

I. General information

NPI: 1538656145
Provider Name (Legal Business Name): KELLY COTALEEN TODD PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25340 1300 EAST ST
WALNUT IL
61376-9274
US

IV. Provider business mailing address

2646 PARK AVE
SAINT LOUIS MO
63104-2024
US

V. Phone/Fax

Practice location:
  • Phone: 815-310-6222
  • Fax:
Mailing address:
  • Phone: 815-310-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberMCS006520B
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2018004205
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number277001500
License Number StateIL

VII. Legacy identifiers

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

# 1
Identifier420071827
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: