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General NPI Number Information
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NPI Number | 1174209704
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Entity Type | Individual
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Provider Name | SANDY NORTHCUTT
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Gender | Female
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Dates
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Enumeration Date | 06/27/2023
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Last Update Date | 09/22/2023
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Provider Practice Location Address
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Address Line | 124 SW ADAMS ST
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City | PEORIA
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State | IL
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Zip | 61602-1308
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Country | US
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Telephone | 888-209-3761
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Fax |
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Provider Business Mailing Address
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Address Line | 252 N 45TH RD
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City | MENDOTA
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State | IL
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Zip | 61342-9427
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Country | US
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Telephone | 815-303-2072
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209.028107
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 163WM0705X
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Taxonomy Name | Medical-Surgical Registered Nurse
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License Number | 041.310284
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License Number State | IL
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