=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477104685
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY ELIZABETH CASOLARI APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2019
-----------------------------------------------------
Last Update Date | 05/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 W WASHINGTON ST
-----------------------------------------------------
City | EAST PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61611-2477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-512-0902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 W CONEFLOWER DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61615-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209.020713
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------