Healthcare Provider Details

I. General information

NPI: 1326020264
Provider Name (Legal Business Name): JEROME W. WELLINGHOFF C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 RIVERKNOLL DR
CHAMPAIGN IL
61822-9213
US

IV. Provider business mailing address

4010 RIVERKNOLL DR
CHAMPAIGN IL
61822-9213
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-5963
  • Fax: 217-352-8947
Mailing address:
  • Phone: 217-356-5963
  • Fax: 217-352-8947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: