Basic Information
| Provider Information | |||||||||
| NPI: | 1215437892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEEFER | ||||||||
| FirstName: | TORY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAXEY, FRITTS | ||||||||
| OtherFirstName: | TORY | ||||||||
| OtherMiddleName: | L. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | FAPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179025291 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2512 HURST DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172585900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2018 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
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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 | 363LF0000X | 209.017195 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209017195 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.