=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366932139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN JEAN MARTIN FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 05/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2560 HAUSER ROSS DR STE 450
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-748-3040
-----------------------------------------------------
Fax | 815-748-3070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 JOHN M BOOR DR
-----------------------------------------------------
City | GILBERTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60136-4063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-629-6941
-----------------------------------------------------
Fax | 815-748-3070
-----------------------------------------------------
=====================================================
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 | 209.017663
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------