Healthcare Provider Details

I. General information

NPI: 1104080779
Provider Name (Legal Business Name): ANDREA LOUISE WINKING RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA LOUISE MACKEY RN BSN

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 WINDISH DRIVE
GALESBURG IL
61401
US

IV. Provider business mailing address

2323 WINDISH DRIVE
GALESBURG IL
61401
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-9461
  • Fax: 309-344-4368
Mailing address:
  • Phone: 309-344-2323
  • Fax: 309-344-4368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041322441
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: