Healthcare Provider Details

I. General information

NPI: 1528601127
Provider Name (Legal Business Name): MICHELLE L GOSNELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2019
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 HAUSER ROSS DR
SYCAMORE IL
60178-3148
US

IV. Provider business mailing address

1625 BETHANY RD
SYCAMORE IL
60178-3124
US

V. Phone/Fax

Practice location:
  • Phone: 779-777-7335
  • Fax: 815-758-8441
Mailing address:
  • Phone: 779-777-7335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209020890
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209020890
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: