Healthcare Provider Details

I. General information

NPI: 1821328584
Provider Name (Legal Business Name): REGAN LEIGH NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 HIGHWAY 14 WEST
CHRISTOPHER IL
62822-0155
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-724-2436
  • Fax:
Mailing address:
  • Phone: 618-724-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049145486
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: