Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 209006132 | IL |
NPI | 1063515385 |
---|---|
Provider Name | Ms. Sally Jane Muich |
First Address | Belleville, IL 62220-1952 |
Second Address | Belleville, IL 62220-1952 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 28/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P68319 | (02) | MO |