Provider Demographics
NPI:1255844189
Name:CHRISTENSEN, KEITH (APN, FNP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:APN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27661 W DRAKE DR APT 244
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-8795
Mailing Address - Country:US
Mailing Address - Phone:815-735-1807
Mailing Address - Fax:
Practice Address - Street 1:1650 MIDTOWN RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1200
Practice Address - Country:US
Practice Address - Phone:815-664-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily