Provider Demographics
NPI:1386836328
Name:PROBST, KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PROBST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4084 REDCASTLE PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7853
Mailing Address - Country:US
Mailing Address - Phone:618-239-6923
Mailing Address - Fax:
Practice Address - Street 1:2319 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1153
Practice Address - Country:US
Practice Address - Phone:618-826-2388
Practice Address - Fax:618-826-3350
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO143113363L00000X
IL209006709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209006709OtherMEDICAL LICENSE NUMBER
ILIL4903001Medicare PIN