Basic Information
| Provider Information | |||||||||
| NPI: | 1255871364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | JORDANNA | ||||||||
| MiddleName: | DYAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHAUFF | ||||||||
| OtherFirstName: | JORDANNA | ||||||||
| OtherMiddleName: | DYAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 E MILLER RD | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156325285 | ||||||||
| FaxNumber: | 8156325824 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610813510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156325285 | ||||||||
| FaxNumber: | 8156325824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2017 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209.015673 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.