Basic Information
| Provider Information | |||||||||
| NPI: | 1548815293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAINE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEARNS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 577 | ||||||||
| Address2: | 109 CALIFORNIA ST | ||||||||
| City: | CARTERRVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199200 | ||||||||
| FaxNumber: | 6189854635 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 S LEWIS LN | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199200 | ||||||||
| FaxNumber: | 6185491288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2019 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 029.019857 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 041441276 | IL | N | Nursing Service Providers | Registered Nurse |
No ID Information.