Active NPI
Stacy Kannenberg
- Student in an Organized Health Care Education/Training Program
- Peoria Heights, IL
National Provider Identifier
1790649986
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Student in an Organized Health Care Education/Training Program
- Practice address
- 1516 E Kelly Ave
Peoria Heights, IL 61616-6512 - Phone
- (309) 657-8779
- NPI assigned
- Dec 11, 2025
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | IL | Primary | |
| Athletic Trainer | 2255A2300X | IL |
Addresses
Primary practice location
1516 E Kelly Ave
Peoria Heights, IL 61616-6512
Mailing address
1516 E Kelly Ave
Peoria Heights, IL 61616-6512
Phone (309) 657-8779
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1765411200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1765411200000",
"number": "1790649986",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1516 E KELLY AVE",
"city": "PEORIA HEIGHTS",
"state": "IL",
"postal_code": "616166512",
"telephone_number": "309-657-8779"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1516 E KELLY AVE",
"city": "PEORIA HEIGHTS",
"state": "IL",
"postal_code": "616166512",
"telephone_number": "309-657-8779"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KANNENBERG",
"first_name": "STACY",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2025-12-11",
"last_updated": "2025-12-11",
"certification_date": "2025-12-11",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "IL",
"license": null,
"primary": true
},
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "IL",
"license": null,
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Peoria Heights, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.