Healthcare Provider Details

I. General information

NPI: 1134240989
Provider Name (Legal Business Name): ILA MAE MINNICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ILA MAE ETHELL RN

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7604 BRIDLEWOOD RD
CALEDONIA IL
61011-9013
US

IV. Provider business mailing address

7604 BRIDLEWOOD RD
CALEDONIA IL
61011-9013
US

V. Phone/Fax

Practice location:
  • Phone: 815-885-1195
  • Fax:
Mailing address:
  • Phone: 815-885-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: