Healthcare Provider Details

I. General information

NPI: 1992742514
Provider Name (Legal Business Name): DIANE STEWART RN/C, APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 W EVERGREEN AVE
EFFINGHAM IL
62401-1619
US

IV. Provider business mailing address

PO BOX 1387 1303 W. EVERGREEN AVE.
EFFINGHAM IL
62401-1387
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-3400
  • Fax: 217-342-6416
Mailing address:
  • Phone: 217-342-3400
  • Fax: 217-342-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209000727
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209000727
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209000727
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number209000727
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041156989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: