Provider Demographics
NPI:1942852389
Name:ROSBOROUGH, KEVIN (PMHNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ROSBOROUGH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PULASKI
Mailing Address - State:IL
Mailing Address - Zip Code:62548-1002
Mailing Address - Country:US
Mailing Address - Phone:217-855-1184
Mailing Address - Fax:
Practice Address - Street 1:1096 1350TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5094
Practice Address - Country:US
Practice Address - Phone:217-735-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017402363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health