=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235015603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAIGE NIEPOETTER FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2025
-----------------------------------------------------
Last Update Date | 08/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 S WATER TOWER PL
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62864-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-246-2910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15435 E BEAL RD
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62864-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-204-2138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209.032935
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------