Individual
KELLY N. CARROLL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
2202 HARLEM RD, LOVES PARK, IL 61111-2754
(815) 877-4848
(815) 636-6125
Mailing address
2202 HARLEM RD, LOVES PARK, IL 61111-2754
(815) 877-4848
(815) 636-6125
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
041.363284
IL
163W00000X
Registered Nurse
172314-30
WI
367500000X
Certified Registered Nurse Anesthetist
Primary
209.011923
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
F400175500
MEDICARE PTAN
IL
01
—
P01459217
RAILROAD MEDICARE
IL
Enumeration date
09/26/2014
Last updated
03/28/2017
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