Healthcare Provider Details

I. General information

NPI: 1073163838
Provider Name (Legal Business Name): TAMISHA BONVILLAIN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 FAIRWAY DR
FREEPORT IL
61032-6600
US

IV. Provider business mailing address

PO BOX 268
FREEPORT IL
61032-0268
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019884
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: