=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184057630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIE MARIE ISHMAEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2013
-----------------------------------------------------
Last Update Date | 07/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HSHS ST. ELIZABETH'S HOSPITAL 1 SAINT ELIZABETH BLVD
-----------------------------------------------------
City | O'FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-234-2120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1496 TADPOLE LN
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-4253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-710-2142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 209010648
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------