Basic Information
| Provider Information | |||||||||
| NPI: | 1447599071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYNTIES | ||||||||
| FirstName: | MONIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 EASTLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617017905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096632100 | ||||||||
| FaxNumber: | 3096638322 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 EASTLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617017905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096632100 | ||||||||
| FaxNumber: | 3096638322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2013 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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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 | 363A00000X | 085-004582 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.