Healthcare Provider Details

I. General information

NPI: 1588251318
Provider Name (Legal Business Name): MICHELLE LYNN STICKELMAIER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LYNN CROUCH APN

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PENNSYLVANIA AVE
PEORIA IL
61603-3089
US

IV. Provider business mailing address

6023 N ANDREWS LN
BRIMFIELD IL
61517-9500
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-4000
  • Fax: 309-624-8522
Mailing address:
  • Phone: 309-219-1446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number209.022202
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number209022202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: