Healthcare Provider Details

I. General information

NPI: 1922962331
Provider Name (Legal Business Name): IXCHEL PAGAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 E STATE ST STE 2
ROCKFORD IL
61108-2165
US

IV. Provider business mailing address

125 WILSON AVE
MACHESNEY PARK IL
61115-2362
US

V. Phone/Fax

Practice location:
  • Phone: 779-217-7020
  • Fax:
Mailing address:
  • Phone: 779-217-7020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.023784
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: