Healthcare Provider Details

I. General information

NPI: 1366218893
Provider Name (Legal Business Name): SYDNEY MARIE GILMER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD STE 110
NORMAL IL
61761-6286
US

IV. Provider business mailing address

2200 FORT JESSE RD STE 110
NORMAL IL
61761-6286
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6290
  • Fax:
Mailing address:
  • Phone: 309-661-6290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209027900
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209027900
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: