Healthcare Provider Details

I. General information

NPI: 1033583125
Provider Name (Legal Business Name): LISA MARIE BUETTNER IDPH #3076
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 COURT ST
PEKIN IL
61554-5481
US

IV. Provider business mailing address

2508 COURT ST
PEKIN IL
61554-5481
US

V. Phone/Fax

Practice location:
  • Phone: 309-346-5323
  • Fax: 309-346-5410
Mailing address:
  • Phone: 309-346-5323
  • Fax: 309-346-5410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3076
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: