Healthcare Provider Details

I. General information

NPI: 1962252486
Provider Name (Legal Business Name): CAROLYNN R BOATFIELD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W HARLEM AVE
MONMOUTH IL
61462
US

IV. Provider business mailing address

1000 W HARLEM AVE
MONMOUTH IL
61462
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-1414
  • Fax: 309-734-0323
Mailing address:
  • Phone: 309-734-1414
  • Fax: 309-734-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: