Healthcare Provider Details

I. General information

NPI: 1699700989
Provider Name (Legal Business Name): IRENE P KASAMBIRA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 NE JEFFERSON
PEORIA IL
61603
US

IV. Provider business mailing address

PO BOX 1346
PEORIA IL
61654-1346
US

V. Phone/Fax

Practice location:
  • Phone: 309-571-8000
  • Fax: 309-671-4695
Mailing address:
  • Phone: 309-671-8000
  • Fax: 309-671-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number209002929
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209008305
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: