Healthcare Provider Details

I. General information

NPI: 1518028398
Provider Name (Legal Business Name): DISTINCTIVE DERMATOLOGYLTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 FULLERTON RD
SWANSEA IL
62226-2970
US

IV. Provider business mailing address

510 FULLERTON ROAD
SWANSEA IL
62226-2970
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7666
  • Fax: 618-233-7461
Mailing address:
  • Phone: 618-233-7666
  • Fax: 618-233-7461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN L. JOURNAGAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-233-7666