Healthcare Provider Details

I. General information

NPI: 1194371104
Provider Name (Legal Business Name): PAMELA SUE FASSBINDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 GALENA SQUARE DRIVE
GALENA IL
61036
US

IV. Provider business mailing address

939 GALENA SQUARE DRIVE
GALENA IL
61036
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-1300
  • Fax: 815-777-1308
Mailing address:
  • Phone: 815-777-1300
  • Fax: 815-777-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number080831
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number041-389191
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: