Healthcare Provider Details

I. General information

NPI: 1932510203
Provider Name (Legal Business Name): TRISHA WIERENGA BSN, RN, IBCLC, RLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WESTPORT CT
BLOOMINGTON IL
61704-8233
US

IV. Provider business mailing address

2016 MARSHALL RD
EUREKA IL
61530-1627
US

V. Phone/Fax

Practice location:
  • Phone: 309-722-4020
  • Fax: 309-740-4440
Mailing address:
  • Phone: 309-370-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-35463
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: