Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | IL |
NPI | 1215111968 |
---|---|
Provider Name | Joan Mommer |
First Address | Rockford, IL 61103-3655 |
Second Address | Rockford, IL 61103-3655 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2007 |
Last Update Date | 18/12/2007 |