Provider Demographics
NPI:1629734264
Name:BEAN, KELLI R (APRN, FPA, FNP-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:R
Last Name:BEAN
Suffix:
Gender:F
Credentials:APRN, FPA, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-0007
Mailing Address - Country:US
Mailing Address - Phone:618-995-8073
Mailing Address - Fax:618-228-4019
Practice Address - Street 1:105 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1458
Practice Address - Country:US
Practice Address - Phone:618-995-8073
Practice Address - Fax:618-822-4019
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024317363LF0000X
IL277003403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily