Provider Demographics
NPI:1689245656
Name:PARK, KELSEY KAY (DNP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:KAY
Last Name:PARK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10551 E 680TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-6367
Mailing Address - Country:US
Mailing Address - Phone:309-202-1898
Mailing Address - Fax:
Practice Address - Street 1:1000 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1114
Practice Address - Country:US
Practice Address - Phone:618-544-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered