Healthcare Provider Details

I. General information

NPI: 1518284348
Provider Name (Legal Business Name): CARRIE L HORACK WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 N KNOXVILLE AVE
PEORIA IL
61604
US

IV. Provider business mailing address

101 PARKEDGE CT
EAST PEORIA IL
61611-4775
US

V. Phone/Fax

Practice location:
  • Phone: 309-253-1701
  • Fax:
Mailing address:
  • Phone: 309-253-1701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209008103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: