Healthcare Provider Details

I. General information

NPI: 1629405907
Provider Name (Legal Business Name): ASHLEY K TENNILL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR
MATTOON IL
61938-4644
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-238-4325
  • Fax: 217-348-4290
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209010744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: