Healthcare Provider Details

I. General information

NPI: 1790453702
Provider Name (Legal Business Name): ANDREA N MACHNACKI APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA LUCACEL

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 N SHERIDAN RD
PEORIA IL
61604-1401
US

IV. Provider business mailing address

11320 N SYCAMORE CREEK DR
DUNLAP IL
61525-2518
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-5100
  • Fax: 309-308-5102
Mailing address:
  • Phone: 734-637-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209023933
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: