Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 209006705 | IL |
NPI | 1003095167 |
---|---|
Provider Name | Jean-Marie Tyner |
First Address | El Paso, IL 61738-1613 |
Second Address | El Paso, IL 61738-1613 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2007 |
Last Update Date | 25/10/2007 |