Healthcare Provider Details

I. General information

NPI: 1467462085
Provider Name (Legal Business Name): CONNIE H REQUARTH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 NORTH MAIN STREET
DECATUR IL
62526-4274
US

IV. Provider business mailing address

2905 NORTH MAIN STREET
DECATUR IL
62526-4274
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-9117
  • Fax: 217-877-3078
Mailing address:
  • Phone: 217-877-9117
  • Fax: 217-877-3082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number041135327
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: