Healthcare Provider Details

I. General information

NPI: 1184057630
Provider Name (Legal Business Name): CASSIE MARIE ISHMAEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 07/28/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HSHS ST. ELIZABETH'S HOSPITAL 1 SAINT ELIZABETH BLVD
O'FALLON IL
62269
US

IV. Provider business mailing address

1496 TADPOLE LN
CENTRALIA IL
62801-4253
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone: 708-710-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209010648
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: