Healthcare Provider Details

I. General information

NPI: 1710645544
Provider Name (Legal Business Name): ANDREA DIANE MCCABE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 02/23/2022
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N MACOUPIN ST
GILLESPIE IL
62033-1408
US

IV. Provider business mailing address

2151 W WHITE OAKS DR
SPRINGFIELD IL
62704-6410
US

V. Phone/Fax

Practice location:
  • Phone: 217-839-3040
  • Fax:
Mailing address:
  • Phone: 217-717-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021039559
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: