Healthcare Provider Details

I. General information

NPI: 1386892784
Provider Name (Legal Business Name): LINDA IDEAN RICH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 MADISON AVE
GRANITE CITY IL
62040-3614
US

IV. Provider business mailing address

4051 KATHY DR APT 4
GRANITE CITY IL
62040-4515
US

V. Phone/Fax

Practice location:
  • Phone: 618-709-7723
  • Fax:
Mailing address:
  • Phone: 928-706-2569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.034190
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: