Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | H098201 | IA |
NPI | 1073979555 |
---|---|
Provider Name | Jill Ballantine |
First Address | Dubuque, IA 52002-2201 |
Second Address | Dubuque, IA 52001-7320 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2016 |
Last Update Date | 13/01/2016 |