Healthcare Provider Details

I. General information

NPI: 1780451104
Provider Name (Legal Business Name): MEGAN ELIZABETH SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-7334
  • Fax: 815-766-9768
Mailing address:
  • Phone: 815-766-7334
  • Fax: 815-766-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209028971
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209028971
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: