Provider Demographics
NPI:1205188661
Name:GRAPPERHAUS, KELLIE (APN)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:
Last Name:GRAPPERHAUS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62858-1053
Mailing Address - Country:US
Mailing Address - Phone:618-665-4500
Mailing Address - Fax:618-665-4050
Practice Address - Street 1:935 BRYANT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:IL
Practice Address - Zip Code:62858-1053
Practice Address - Country:US
Practice Address - Phone:618-665-4500
Practice Address - Fax:618-665-4050
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily