Healthcare Provider Details

I. General information

NPI: 1518402064
Provider Name (Legal Business Name): BLAIR ELIZABETH BONE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13745 MARY LN
AVISTON IL
62216-4732
US

IV. Provider business mailing address

PO BOX 306
COLUMBIA IL
62236-0306
US

V. Phone/Fax

Practice location:
  • Phone: 618-567-9821
  • Fax: 618-939-9836
Mailing address:
  • Phone: 618-567-9821
  • Fax: 618-939-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209105303
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.015303
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: