Healthcare Provider Details

I. General information

NPI: 1720165103
Provider Name (Legal Business Name): BONNIE JEAN COBURN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 E US ROUTE 36
DECATUR IL
62521-5003
US

IV. Provider business mailing address

4965 E LOST BRIDGE RD
DECATUR IL
62521-5139
US

V. Phone/Fax

Practice location:
  • Phone: 217-588-2600
  • Fax:
Mailing address:
  • Phone: 217-864-5531
  • Fax: 217-864-2449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000529
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209006142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: