Basic Information
| Provider Information | |||||||||
| NPI: | 1093904179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMBODEN | ||||||||
| FirstName: | ANNIE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Practice Location | |||||||||
| Address1: | 3412 OFFICE PARK DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629596477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 12/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 209.006809 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.