Provider Demographics
NPI:1386851053
Name:NACKE, KATHLEEN ANN (NNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:NACKE
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19676
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9676
Mailing Address - Country:US
Mailing Address - Phone:800-331-2229
Mailing Address - Fax:217-757-6844
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:4W16
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:800-331-2229
Practice Address - Fax:217-757-6844
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002084363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL522000013Medicare PIN