Healthcare Provider Details

I. General information

NPI: 1023079357
Provider Name (Legal Business Name): NANCY MCCRISKIN ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 EAST EMERSON ILLINOIS WESLEYAN UNIVERSITY TRAINING ROOM
BLOOMINGTON IL
61702
US

IV. Provider business mailing address

25085 EAGLE PT
HUDSON IL
61748-7505
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-3601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: