=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366312548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE MICHELE GILL PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2025
-----------------------------------------------------
Last Update Date | 11/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1709 JUMER DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-0914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-825-5679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 BURGANDY CT
-----------------------------------------------------
City | MACKINAW
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61755-9448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-825-5679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 041418412
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------