Provider Demographics
NPI:1164806493
Name:KNACKSTEDT, KELLY (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KNACKSTEDT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:IL
Mailing Address - Zip Code:62001-0027
Mailing Address - Country:US
Mailing Address - Phone:618-488-2694
Mailing Address - Fax:
Practice Address - Street 1:1285 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1778
Practice Address - Country:US
Practice Address - Phone:217-324-6127
Practice Address - Fax:217-324-9293
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012036019163W00000X
IL041.407486163W00000X
IL209019036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.019036Medicaid