Healthcare Provider Details

I. General information

NPI: 1194022368
Provider Name (Legal Business Name): CARRIE M CUNNINGHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S MAIN ST
PARIS IL
61944
US

IV. Provider business mailing address

2200 S MAIN ST
PARIS IL
61944-2966
US

V. Phone/Fax

Practice location:
  • Phone: 217-463-4340
  • Fax: 217-463-4342
Mailing address:
  • Phone: 217-463-4340
  • Fax: 217-463-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28179464A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: