Healthcare Provider Details

I. General information

NPI: 1477822344
Provider Name (Legal Business Name): WENJING CAO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W. MARKET
BLOOMINGTON IL
61701
US

IV. Provider business mailing address

108 W. MARKET
BLOOMINGTON IL
61701
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-5351
  • Fax: 309-829-6808
Mailing address:
  • Phone: 309-827-5351
  • Fax: 309-829-6808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3007133
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209009448
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number309.005775
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: