Healthcare Provider Details

I. General information

NPI: 1194324004
Provider Name (Legal Business Name): ELIZABETH LEA BIRDSLEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 S CONGRESS ST
RUSHVILLE IL
62681-1409
US

IV. Provider business mailing address

1375 RESERVOIR RD
CONCORD IL
62631-5012
US

V. Phone/Fax

Practice location:
  • Phone: 217-322-3345
  • Fax:
Mailing address:
  • Phone: 217-323-2118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.021857
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: