Healthcare Provider Details

I. General information

NPI: 1376192567
Provider Name (Legal Business Name): HEART TO HEART PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 BRADFORD LN
WATERLOO IL
62298-3369
US

IV. Provider business mailing address

224 BRADFORD LN
WATERLOO IL
62298-3369
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-0112
  • Fax:
Mailing address:
  • Phone: 618-939-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GINNY M PETER
Title or Position: NURSE PRACTITIONER
Credential: CPNP
Phone: 618-939-0112