Healthcare Provider Details

I. General information

NPI: 1306350780
Provider Name (Legal Business Name): ANGELA SUE BIRDSELL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

102 S MARY ST
ATLANTA IL
61723-8993
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-4321
  • Fax: 309-663-8032
Mailing address:
  • Phone: 217-737-1694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016781
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: