Healthcare Provider Details

I. General information

NPI: 1518204833
Provider Name (Legal Business Name): JENNIFER LYNN MUSGRAVE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 NW 11TH ST
FAIRFIELD IL
62837-1218
US

IV. Provider business mailing address

4241 HIGHWAY 14 WEST
CHRISTOPHER IL
62822
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4470
  • Fax:
Mailing address:
  • Phone: 618-724-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041403861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: