Provider Demographics
NPI:1013674993
Name:ANDERSON, KELLEY MARIE (APN)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4203
Mailing Address - Country:US
Mailing Address - Phone:815-735-7137
Mailing Address - Fax:
Practice Address - Street 1:5721 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1425
Practice Address - Country:US
Practice Address - Phone:773-702-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024433363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care