Provider Demographics
NPI:1508341181
Name:EVANS, KELLY S (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:EVANS
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 1:1414 CROSS ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2988
Mailing Address - Country:US
Mailing Address - Phone:618-607-1260
Mailing Address - Fax:
Practice Address - Street 1:1414 CROSS ST STE 230
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:618-607-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017964363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner