Healthcare Provider Details

I. General information

NPI: 1518118140
Provider Name (Legal Business Name): TERESA DAWN MEJORADO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6230
  • Fax: 309-664-3461
Mailing address:
  • Phone: 309-661-6230
  • Fax: 309-664-3461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-001992
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: