Provider Demographics
NPI:1700214749
Name:KELLEY, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-0309
Mailing Address - Country:US
Mailing Address - Phone:309-370-1951
Mailing Address - Fax:609-323-0447
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-999-1091
Practice Address - Fax:309-999-1094
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010398363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400107223Medicare PIN
ILF400107224Medicare PIN