MEDICARE: MRS. TINA LOUISE VALENTINE CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	106770	MO
2	363L00000X	Nurse Practitioner	209-001032	IL

General Provider Information

NPI Number	:	1356337224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TINA LOUISE VALENTINE CNP

Provider Business Mailing Address
First Line	:	14 PRAIRIE VIEW EST
Second Line	:
City	:	COLUMBIA
State	:	IL
Zip	:	62236-3336
Country	:	US
Telephone Number	:	618-476-7870
Fax Number	:	618-476-7853

Provider Business Practice Location Address
First Line	:	421 S MAIN ST
Second Line	:
City	:	COLUMBIA
State	:	IL
Zip	:	62236-2460
Country	:	US
Telephone Number	:	618-281-7151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	03/17/2021

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