Provider Demographics
NPI:1972092716
Name:JIMENEZ, KELSEY RENEE (FNP - BC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:RENEE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:FNP - BC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:RENEE
Other - Last Name:TASSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP - BC
Mailing Address - Street 1:1296 BEED AVE
Mailing Address - Street 2:
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119-7826
Mailing Address - Country:US
Mailing Address - Phone:248-224-4086
Mailing Address - Fax:
Practice Address - Street 1:1180 W WILSON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510
Practice Address - Country:US
Practice Address - Phone:630-879-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily