Healthcare Provider Details

I. General information

NPI: 1174209704
Provider Name (Legal Business Name): SANDY NORTHCUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SW ADAMS ST
PEORIA IL
61602-1308
US

IV. Provider business mailing address

252 N 45TH RD
MENDOTA IL
61342-9427
US

V. Phone/Fax

Practice location:
  • Phone: 888-209-3761
  • Fax:
Mailing address:
  • Phone: 815-303-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.028107
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number041.310284
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: