Healthcare Provider Details

I. General information

NPI: 1144515610
Provider Name (Legal Business Name): BRETT ALLEN NANCE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S 3RD ST SUITE 400
BELLEVILLE IL
62220-1952
US

IV. Provider business mailing address

180 S 3RD ST SUITE 400
BELLEVILLE IL
62220-1952
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7880
  • Fax: 618-222-4792
Mailing address:
  • Phone: 618-233-7880
  • Fax: 618-222-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.059709
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8570024-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: