Healthcare Provider Details

I. General information

NPI: 1114196904
Provider Name (Legal Business Name): SUMMER L PARK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUMMER L ROESCHLEY APN

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 WINDSOR RD
CHAMPAIGN IL
61822-6217
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-6104
  • Fax: 217-366-6106
Mailing address:
  • Phone: 217-366-1326
  • Fax: 217-366-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209006933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: