Healthcare Provider Details

I. General information

NPI: 1750866620
Provider Name (Legal Business Name): THOMAS W HEFNER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 W 3RD ST
BONNIE IL
62816-1002
US

IV. Provider business mailing address

365 W 3RD ST
BONNIE IL
62816-1002
US

V. Phone/Fax

Practice location:
  • Phone: 618-967-2666
  • Fax:
Mailing address:
  • Phone: 618-967-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.018248
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: