Provider Demographics
NPI:1245765296
Name:THACKER, KELSEY MARIE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:THACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ASHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MT. ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549
Mailing Address - Country:US
Mailing Address - Phone:217-864-2665
Mailing Address - Fax:217-864-8042
Practice Address - Street 1:104 E ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1271
Practice Address - Country:US
Practice Address - Phone:217-864-2665
Practice Address - Fax:217-864-8042
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner