Healthcare Provider Details

I. General information

NPI: 1629546411
Provider Name (Legal Business Name): LISA JO SUWANAWONGSE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DR WARREN TUTTLE DR
HARRISBURG IL
62946-2718
US

IV. Provider business mailing address

PO BOX 428
HARRISBURG IL
62946-0428
US

V. Phone/Fax

Practice location:
  • Phone: 618-253-7671
  • Fax: 618-253-0474
Mailing address:
  • Phone: 618-253-7671
  • Fax: 618-253-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016422
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: