Healthcare Provider Details

I. General information

NPI: 1003648403
Provider Name (Legal Business Name): PAYTON HUFNAGEL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 N SHERIDAN RD
PEORIA IL
61614-2932
US

IV. Provider business mailing address

5250 N KNOXVILLE AVE APT 517
PEORIA IL
61614-5042
US

V. Phone/Fax

Practice location:
  • Phone: 309-883-5070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070028375
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: