Healthcare Provider Details

I. General information

NPI: 1043683584
Provider Name (Legal Business Name): ELIZABETH FERN GEPHART RN, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N 16TH ST
SPRINGFIELD IL
62703-1101
US

IV. Provider business mailing address

101 N 16TH ST
SPRINGFIELD IL
62703-1101
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-6522
  • Fax:
Mailing address:
  • Phone: 217-525-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041.185284
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.000473
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: