MEDICARE: ALLYSON K. GOUGH APRN, BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041333130	IL
2	363L00000X	Nurse Practitioner	209004629	IL
3	364SA2200X	Adult Health Clinical Nurse Specialist	209004629	IL
4	364SM0705X	Medical-Surgical Clinical Nurse Specialist	209004629	IL
5	363LA2200X	Adult Health Nurse Practitioner	209004629	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	517490	OTHER	IL	HEALTHLINK

General Provider Information

NPI Number	:	1336196609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLYSON K. GOUGH APRN, BC

Provider Business Mailing Address
First Line	:	1005 HEALTH CENTER DR STE 201
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4693
Country	:	US
Telephone Number	:	217-238-6055
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 HEALTH CENTER DR STE 107
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9253
Country	:	US
Telephone Number	:	217-238-4960
Fax Number	:	217-238-4951

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2006
Last Update Date	:	11/27/2018

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