Basic Information
| Provider Information | |||||||||
| NPI: | 1619400447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNM, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 544 W PERSHING RD STE A | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 544 W PERSHING RD STE A | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 209.015343 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.