Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 209014167 | IL |
NPI | 1003370982 |
---|---|
Provider Name | Cheryl Hansen |
First Address | Pontiac, IL 61764-3291 |
Second Address | Pontiac, IL 61764-2323 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2019 |
Last Update Date | 25/01/2019 |