Provider Demographics
NPI:1609173434
Name:GIBBONS, KELLIE J (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:J
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:650 W STATE STREET
Mailing Address - Street 2:WINNEBAGO COUNTY JAIL MEDICAL UNIT
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-0000
Mailing Address - Country:US
Mailing Address - Phone:815-319-6630
Mailing Address - Fax:815-962-6425
Practice Address - Street 1:650 W STATE STREET
Practice Address - Street 2:WINNEBAGO COUNTY JAIL MEDICAL UNIT
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-0000
Practice Address - Country:US
Practice Address - Phone:815-319-6630
Practice Address - Fax:815-962-6425
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041335792163W00000X
IL209008646363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041335792OtherRN LICENSE