Healthcare Provider Details

I. General information

NPI: 1215408968
Provider Name (Legal Business Name): LADAWNA JO ROYER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E GRANT ST
MACOMB IL
61455-3313
US

IV. Provider business mailing address

525 E GRANT ST
MACOMB IL
61455-3318
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-4101
  • Fax:
Mailing address:
  • Phone: 309-255-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018495
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: