Provider Demographics
NPI:1417830803
Name:DESMARAIS, KELLY (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DESMARAIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15776 HERBERGER RD
Mailing Address - Street 2:
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755-9221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 N WILLIAM KUMPF BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2531
Practice Address - Country:US
Practice Address - Phone:309-624-9934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.032862363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner