Basic Information
| Provider Information | |||||||||
| NPI: | 1508319914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PILLER | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNAPP | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1405 E 12TH ST | ||||||||
| Address2: | STE 600 | ||||||||
| City: | MENDOTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613429010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155387200 | ||||||||
| FaxNumber: | 8155391444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 E 12TH ST | ||||||||
| Address2: | STE 600 | ||||||||
| City: | MENDOTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613429010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155387200 | ||||||||
| FaxNumber: | 8155391444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041289414 | IL | N | Nursing Service Providers | Registered Nurse | 363L00000X | 209-014728 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.