Healthcare Provider Details

I. General information

NPI: 1033494455
Provider Name (Legal Business Name): MANEESHA T JOSEPH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANEESHA T POULOSE

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE SUITE 3400
NORMAL IL
61761-3551
US

IV. Provider business mailing address

1302 FRANKLIN AVE SUITE 3400
NORMAL IL
61761-3551
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-8300
  • Fax: 309-556-8295
Mailing address:
  • Phone: 309-556-8300
  • Fax: 309-556-8295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number041.394485
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number582593-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN 9300306
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF336606-1
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.008939
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: