Provider Demographics
NPI:1760770085
Name:WILLENBORG, KATHY A (RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:WILLENBORG
Suffix:
Gender:F
Credentials:RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1652
Mailing Address - Country:US
Mailing Address - Phone:618-202-6441
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1652
Practice Address - Country:US
Practice Address - Phone:618-202-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016361363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health