Healthcare Provider Details

I. General information

NPI: 1013672682
Provider Name (Legal Business Name): HANNAH THERESA MATVIKO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 W NORTH ST
MANHATTAN IL
60442-9839
US

IV. Provider business mailing address

380 W NORTH ST
MANHATTAN IL
60442-9839
US

V. Phone/Fax

Practice location:
  • Phone: 815-802-0077
  • Fax: 815-418-3005
Mailing address:
  • Phone: 815-802-0077
  • Fax: 815-418-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28266008A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011958A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209024267
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: