Healthcare Provider Details

I. General information

NPI: 1508368309
Provider Name (Legal Business Name): STEPHANIE D YEAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE D SANDERS

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9951 ROCK CUT XING
LOVES PARK IL
61111-1999
US

IV. Provider business mailing address

9951 ROCK CUT XING
LOVES PARK IL
61111-1999
US

V. Phone/Fax

Practice location:
  • Phone: 815-639-8500
  • Fax: 815-639-8501
Mailing address:
  • Phone: 815-639-8500
  • Fax: 815-639-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017266
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: