Healthcare Provider Details

I. General information

NPI: 1881321107
Provider Name (Legal Business Name): NICOLE L GARNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE L BEAVERS PA-C

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E LAKE SHORE DR STE 200
DECATUR IL
62521-3806
US

IV. Provider business mailing address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-1460
  • Fax:
Mailing address:
  • Phone: 217-547-9100
  • Fax: 217-547-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: