MEDICARE: KATHY MARREN GNP

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
1	363LG0600X	Gerontology Nurse Practitioner	083575	MO
2	363LG0600X	Gerontology Nurse Practitioner	041362173	IL

General Provider Information

NPI Number	:	1568430379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY MARREN GNP

Provider Business Mailing Address
First Line	:	101 W UNIVERSITY AVE
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61820-3909
Country	:	US
Telephone Number	:	217-366-1326
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 WINDSOR RD
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-6217
Country	:	US
Telephone Number	:	217-366-5434
Fax Number	:	217-366-6106

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	09/02/2011

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