Healthcare Provider Details

I. General information

NPI: 1376539783
Provider Name (Legal Business Name): JOSEPH LEE EASLEY PNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 HAWTHORN RD
SALEM IL
62881-1028
US

IV. Provider business mailing address

1275 HAWTHORN RD
SALEM IL
62881-1028
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-4590
  • Fax: 618-548-8275
Mailing address:
  • Phone: 618-548-4590
  • Fax: 618-548-8275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN28947
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: