Healthcare Provider Details

I. General information

NPI: 1871760173
Provider Name (Legal Business Name): MISS KRISTA L RUESTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 GILL ST STE 3
BLOOMINGTON IL
61704-3438
US

IV. Provider business mailing address

433 E 7TH ST
MINONK IL
61760-1105
US

V. Phone/Fax

Practice location:
  • Phone: 309-846-4716
  • Fax:
Mailing address:
  • Phone: 309-432-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: