Healthcare Provider Details

I. General information

NPI: 1538939145
Provider Name (Legal Business Name): DONNETTA HOUSE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NORTHGATE INDUSTRIAL DR
GRANITE CITY IL
62040-6805
US

IV. Provider business mailing address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

V. Phone/Fax

Practice location:
  • Phone: 618-877-4420
  • Fax:
Mailing address:
  • Phone: 888-924-3786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.035986
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2016025238
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: