Provider Demographics
NPI:1336659838
Name:WASMUTH, KELSY BRIKAY (FNP)
Entity Type:Individual
Prefix:
First Name:KELSY
Middle Name:BRIKAY
Last Name:WASMUTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 STE 100
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8560
Mailing Address - Country:US
Mailing Address - Phone:618-288-3616
Mailing Address - Fax:618-288-3647
Practice Address - Street 1:6810 STATE ROUTE 162 STE 100
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8560
Practice Address - Country:US
Practice Address - Phone:618-288-3616
Practice Address - Fax:618-288-3647
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016647363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209016647OtherLICENSE