Provider Demographics
NPI:1467827592
Name:KARR, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:AUGSBURGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:309-663-2100
Mailing Address - Fax:309-663-8322
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3534
Practice Address - Country:US
Practice Address - Phone:309-663-2100
Practice Address - Fax:309-663-8322
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-370455163W00000X
IL209-013789363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare PIN