=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861867863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED PRACTICE NURSING SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2015
-----------------------------------------------------
Last Update Date | 08/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 746 URBANNA DR
-----------------------------------------------------
City | FREEBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62243-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-792-3586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 303
-----------------------------------------------------
City | MASCOUTAH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62258-0303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-792-3586
-----------------------------------------------------
Fax | 636-333-4510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KELLY WHITAKER
-----------------------------------------------------
Credential | ANP
-----------------------------------------------------
Telephone | 618-792-3586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------