Provider Demographics
NPI:1083155311
Name:HAVLIN, KACI N
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:N
Last Name:HAVLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KACI
Other - Middle Name:N
Other - Last Name:RIDDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:15 FOUNDERS LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3919
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily