Healthcare Provider Details

I. General information

NPI: 1447769724
Provider Name (Legal Business Name): WAYLAND J MUTTER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1025 MAINE ST
QUINCY IL
62301-4038
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-1200
  • Fax:
Mailing address:
  • Phone: 217-222-6550
  • Fax: 217-277-2253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041326848
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: