Healthcare Provider Details

I. General information

NPI: 1912756339
Provider Name (Legal Business Name): MINETTE ROQUE SAMPANG PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 NEAL AVE
JOLIET IL
60433-2548
US

IV. Provider business mailing address

1106 NEAL AVE
JOLIET IL
60433-2548
US

V. Phone/Fax

Practice location:
  • Phone: 815-727-8670
  • Fax:
Mailing address:
  • Phone: 815-727-8670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209029652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: