Provider Demographics
NPI:1679676738
Name:BLAGG, KELLI LYNN (FNP APN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:BLAGG
Suffix:
Gender:F
Credentials:FNP APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 HAMACHER ST 205
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-628-0715
Mailing Address - Fax:888-371-4468
Practice Address - Street 1:10555 EAST COUNTY ROAD 800 N
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-3574
Practice Address - Country:US
Practice Address - Phone:217-235-4227
Practice Address - Fax:217-235-4274
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00322001OtherRAILROAD MEDICARE
ILP00322001OtherRAILROAD MEDICARE