Healthcare Provider Details

I. General information

NPI: 1992668297
Provider Name (Legal Business Name): BOBBIE JOLEEN HAUTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

28801 QUEENWOOD RD
MORTON IL
61550-9211
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax:
Mailing address:
  • Phone: 309-231-8042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041334283
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: