Healthcare Provider Details

I. General information

NPI: 1104478932
Provider Name (Legal Business Name): BENJAMIN NEWELL WINDHAM APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 12/24/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E GROVE AVE
RANTOUL IL
61866-2736
US

IV. Provider business mailing address

611 W PARK FAPC
URBANA IL
61802
US

V. Phone/Fax

Practice location:
  • Phone: 217-893-7700
  • Fax:
Mailing address:
  • Phone: 217-902-6954
  • Fax: 217-902-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030250
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: