Healthcare Provider Details

I. General information

NPI: 1114402518
Provider Name (Legal Business Name): MICHELLE LEE GEISS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

IV. Provider business mailing address

70 NAVAJO DR
SPRINGFIELD IL
62711-6084
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-7275
  • Fax:
Mailing address:
  • Phone: 309-210-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.018271
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: