Healthcare Provider Details

I. General information

NPI: 1104700111
Provider Name (Legal Business Name): HEALING MANTLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5117 JACKS BLVD
CHAMPAIGN IL
61822-3656
US

IV. Provider business mailing address

5117 JACKS BLVD
CHAMPAIGN IL
61822-3656
US

V. Phone/Fax

Practice location:
  • Phone: 217-318-1860
  • Fax:
Mailing address:
  • Phone: 217-318-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name: INA MEDINA WILLIAMS
Title or Position: MANAGING MEMBER
Credential: RN
Phone: 217-318-1860