Basic Information
| Provider Information | |||||||||
| NPI: | 1336196609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUGH | ||||||||
| FirstName: | ALLYSON | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | APRN, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HEALTH CENTER DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172384960 | ||||||||
| FaxNumber: | 2172384951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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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 | 163W00000X | 041333130 | IL | N | Nursing Service Providers | Registered Nurse | 363L00000X | 209004629 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SA2200X | 209004629 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 364SM0705X | 209004629 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical | 363LA2200X | 209004629 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 517490 | 01 | IL | HEALTHLINK | OTHER |