Healthcare Provider Details

I. General information

NPI: 1114358264
Provider Name (Legal Business Name): LAURAN E MEJIA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16129 KELLEY RD
PECATONICA IL
61063-9449
US

IV. Provider business mailing address

2222 E STATE ST SUITE 209
ROCKFORD IL
61104-1573
US

V. Phone/Fax

Practice location:
  • Phone: 815-329-3959
  • Fax:
Mailing address:
  • Phone: 815-988-8500
  • Fax: 815-977-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.0011007
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: