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NPI Code Detail

MEDICARE: KELCY MARIE CARLSON PMHNP-BC

MEDICARE: KELCY MARIE CARLSON PMHNP-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse Practitioner209023657IL

General Provider Information

NPI Number : 1124792288
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELCY MARIE CARLSON PMHNP-BC
Provider Business Mailing Address
First Line : 2900 ILLINOIS ROUTE 15
Second Line :
City : ELLERY
State : IL
Zip : 62833-4409
Country : US
Telephone Number : 618-302-3199
Fax Number :
Provider Business Practice Location Address
First Line : 363 N WEST ST
Second Line :
City : OLNEY
State : IL
Zip : 62450-1160
Country : US
Telephone Number : 618-392-9400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/03/2021
Last Update Date : 08/03/2021

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Directions to “ KELCY MARIE CARLSON PMHNP-BC” Practice Location

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