Healthcare Provider Details

I. General information

NPI: 1134966542
Provider Name (Legal Business Name): KRISHNA VANI NEMALIDINNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PROFESSIONAL PLAZA
MATTOON IL
61938
US

IV. Provider business mailing address

420 NE GLEN OAK AVE STE 401
PEORIA IL
61603
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-8123
  • Fax: 309-676-8455
Mailing address:
  • Phone: 309-676-8123
  • Fax: 309-676-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036180896
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036180896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: