Healthcare Provider Details

I. General information

NPI: 1174028971
Provider Name (Legal Business Name): ARI ALEXANDRA PENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WINDSOR RD
CHAMPAIGN IL
61822-6217
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1174028971
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036160991
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: