Healthcare Provider Details

I. General information

NPI: 1396365102
Provider Name (Legal Business Name): LAUREN AILEEN BUNNER CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST # 4W16
SPRINGFIELD IL
62702-5303
US

IV. Provider business mailing address

201 E MADISON ST STE 328
SPRINGFIELD IL
62702-5131
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041429321
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209025098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: