Healthcare Provider Details

I. General information

NPI: 1912817057
Provider Name (Legal Business Name): STEPHANIE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SAINT CLARE CT
WASHINGTON IL
61571-9239
US

IV. Provider business mailing address

10927 N TUSCANY RIDGE CT
DUNLAP IL
61525-7516
US

V. Phone/Fax

Practice location:
  • Phone: 309-886-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number041366527
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: