Healthcare Provider Details

I. General information

NPI: 1104082890
Provider Name (Legal Business Name): CATHERINE ELIZABETH THEORELL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2500
US

IV. Provider business mailing address

PO BOX 6002
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3266
  • Fax: 217-383-3463
Mailing address:
  • Phone: 217-326-8630
  • Fax: 312-996-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number209.004131041.16740
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: