Healthcare Provider Details

I. General information

NPI: 1619584653
Provider Name (Legal Business Name): CRAIG H DUTTON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 IL ROUTE 146 E
ELIZABETHTOWN IL
62931-4015
US

IV. Provider business mailing address

609 IL ROUTE 146 E
ELIZABETHTOWN IL
62931-4015
US

V. Phone/Fax

Practice location:
  • Phone: 618-289-4858
  • Fax:
Mailing address:
  • Phone: 618-499-9648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.021921
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: