Healthcare Provider Details

I. General information

NPI: 1376417253
Provider Name (Legal Business Name): STEFANIE POETTKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S LINCOLN BLVD
CENTRALIA IL
62801-3654
US

IV. Provider business mailing address

15487 E TOLLE RD
MOUNT VERNON IL
62864-8364
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-0404
  • Fax:
Mailing address:
  • Phone: 618-204-2344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.033426
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: