Provider Demographics
NPI:1386158822
Name:DETWEILER, KERRY (APN)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:
Other - Last Name:MALONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9727
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9727
Mailing Address - Country:US
Mailing Address - Phone:309-886-9172
Mailing Address - Fax:
Practice Address - Street 1:3525 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1324
Practice Address - Country:US
Practice Address - Phone:309-886-9172
Practice Address - Fax:309-509-4045
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002153363LF0000X
KY3018521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily