Healthcare Provider Details

I. General information

NPI: 1679903066
Provider Name (Legal Business Name): LAURA HUTCHESON I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

IV. Provider business mailing address

109 NANETTE DR
BELLEVILLE IL
62223-1837
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7750
  • Fax:
Mailing address:
  • Phone: 618-795-8195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.369846
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: