Healthcare Provider Details

I. General information

NPI: 1629292123
Provider Name (Legal Business Name): DOROTHY J LOOP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S DEER RD
MACOMB IL
61455-2639
US

IV. Provider business mailing address

11510 N 950TH RD
MACOMB IL
61455-7972
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-4876
  • Fax:
Mailing address:
  • Phone: 309-833-5354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number041.113213
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041.113213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: