Provider Demographics
NPI:1821646639
Name:GRANNIS, KELLY K (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:GRANNIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:KULINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:60 REVERE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1590
Mailing Address - Country:US
Mailing Address - Phone:224-306-1879
Mailing Address - Fax:224-306-1878
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1700
Practice Address - Country:US
Practice Address - Phone:847-570-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019940363L00000X
IL209.019940363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner