Healthcare Provider Details

I. General information

NPI: 1477287183
Provider Name (Legal Business Name): LARISA SAVAGE APN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 OLT AVE
PEKIN IL
61554-6214
US

IV. Provider business mailing address

2214 N UNIVERSITY ST
PEORIA IL
61604-3221
US

V. Phone/Fax

Practice location:
  • Phone: 309-680-7600
  • Fax: 309-353-3334
Mailing address:
  • Phone: 309-495-8644
  • Fax: 309-681-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209025530
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041467219
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: