Healthcare Provider Details

I. General information

NPI: 1508241761
Provider Name (Legal Business Name): EMILY NIELSEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 N RUTLEDGE ST
SPRINGFIELD IL
62702-3721
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3948
  • Fax:
Mailing address:
  • Phone: 217-788-3948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012964
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: