Healthcare Provider Details

I. General information

NPI: 1194723312
Provider Name (Legal Business Name): RICKI LOAR APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

IV. Provider business mailing address

3553 W PETERSON AVE SUITE 105
CHICAGO IL
60659-3200
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-2094
  • Fax: 618-607-5127
Mailing address:
  • Phone: 773-267-3807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0086728
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209001078
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209-001078
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-001078
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR0086728
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: