Healthcare Provider Details

I. General information

NPI: 1750756979
Provider Name (Legal Business Name): MISKELL MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W MADISON ST
OTTAWA IL
61350-2819
US

IV. Provider business mailing address

218 W MADISON ST
OTTAWA IL
61350-2819
US

V. Phone/Fax

Practice location:
  • Phone: 815-431-1122
  • Fax: 815-431-0318
Mailing address:
  • Phone: 815-431-1122
  • Fax: 815-431-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number209009286
License Number StateIL

VIII. Authorized Official

Name: JESSICA MISKELL
Title or Position: OWNER/PROVIDER
Credential: FNP
Phone: 815-431-1122