Healthcare Provider Details

I. General information

NPI: 1609272533
Provider Name (Legal Business Name): MIA MCDERMOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 22ND AVE
MONROE WI
53566-1569
US

IV. Provider business mailing address

101 E MILLER RD
STERLING IL
61081-1252
US

V. Phone/Fax

Practice location:
  • Phone: 608-324-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209012104
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: