Healthcare Provider Details

I. General information

NPI: 1235015603
Provider Name (Legal Business Name): PAIGE NIEPOETTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 S WATER TOWER PL
MOUNT VERNON IL
62864-2349
US

IV. Provider business mailing address

15435 E BEAL RD
MOUNT VERNON IL
62864-5616
US

V. Phone/Fax

Practice location:
  • Phone: 618-246-2910
  • Fax:
Mailing address:
  • Phone: 618-204-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.032935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: