Healthcare Provider Details

I. General information

NPI: 1851891170
Provider Name (Legal Business Name): LUKE RAY ZUMBAHLEN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 HEALTH CENTER DR STE 104
MATTOON IL
61938-4637
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2178
  • Fax: 217-258-4024
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017079
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: