Healthcare Provider Details

I. General information

NPI: 1376459776
Provider Name (Legal Business Name): DAVID PIERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13745 MARY LN
AVISTON IL
62216-4732
US

IV. Provider business mailing address

13745 MARY LN
AVISTON IL
62216-4732
US

V. Phone/Fax

Practice location:
  • Phone: 618-560-6322
  • Fax:
Mailing address:
  • Phone: 618-560-6322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041443612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: