Healthcare Provider Details

I. General information

NPI: 1518158914
Provider Name (Legal Business Name): JODY K GURTLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W. CURTIS ROAD PEDIATRICS
CHAMPAIGN IL
61822
US

IV. Provider business mailing address

PO BOX 6004
URBANA IL
61803-6004
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6202
  • Fax: 217-326-1234
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number209004436
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209004436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: