Healthcare Provider Details

I. General information

NPI: 1316314933
Provider Name (Legal Business Name): MARLISSA BOYLES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S WHITTLE AVE
OLNEY IL
62450-2262
US

IV. Provider business mailing address

405 S WHITTLE AVE
OLNEY IL
62450-2262
US

V. Phone/Fax

Practice location:
  • Phone: 618-364-1009
  • Fax:
Mailing address:
  • Phone: 618-364-1009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.013074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: