Healthcare Provider Details

I. General information

NPI: 1730632407
Provider Name (Legal Business Name): JOANNA HUTSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E CONGRESS PKWY SUITE C
CRYSTAL LAKE IL
60014-6202
US

IV. Provider business mailing address

120 W 22ND ST STE 200
OAK BROOK IL
60523-1563
US

V. Phone/Fax

Practice location:
  • Phone: 815-301-1001
  • Fax: 815-301-1002
Mailing address:
  • Phone: 630-575-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.014557
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: