MEDICARE: MRS. BRANDI MAE HEINECKE FNP

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	363LF0000X	Family Nurse Practitioner	209013521	IL

General Provider Information

NPI Number	:	1821530817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRANDI MAE HEINECKE FNP

Provider Business Mailing Address
First Line	:	1604 CLEVELAND RD
Second Line	:
City	:	COLONA
State	:	IL
Zip	:	61241-8970
Country	:	US
Telephone Number	:	309-949-2999
Fax Number	:

Provider Business Practice Location Address
First Line	:	1604 CLEVELAND RD
Second Line	:
City	:	COLONA
State	:	IL
Zip	:	61241-8970
Country	:	US
Telephone Number	:	309-949-2999
Fax Number	:

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

Provider Enumeration Date	:	11/08/2016
Last Update Date	:	11/08/2016

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