Provider Demographics
NPI:1790760080
Name:ROSENBERGER, KELLY D (CNM, NP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:D
Last Name:ROSENBERGER
Suffix:
Gender:F
Credentials:CNM, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:CREDENTIALING S200
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5861
Mailing Address - Fax:815-395-5575
Practice Address - Street 1:1221 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2231
Practice Address - Country:US
Practice Address - Phone:815-972-1000
Practice Address - Fax:815-972-1086
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000443363LW0102X
IL209008138367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209000443OtherSTATE LICENSE
ILS49918Medicare UPIN
IL209000443OtherSTATE LICENSE