Healthcare Provider Details

I. General information

NPI: 1902276207
Provider Name (Legal Business Name): LYNETTE EETEN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNETTE EDWARDS

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-649-6880
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-649-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.013158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: