Healthcare Provider Details

I. General information

NPI: 1295591634
Provider Name (Legal Business Name): DEACONESS CLINC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 W DEYOUNG ST
MARION IL
62959-5884
US

IV. Provider business mailing address

PO BOX 631767
CINCINNATI OH
45263-1767
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-6966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANNETTE WATHEN
Title or Position: CFO
Credential:
Phone: 812-450-3296