Basic Information
| Provider Information | |||||||||
| NPI: | 1568444008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | EVELEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | CREDENTIALING S200 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955861 | ||||||||
| FaxNumber: | 8153955575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 E STATE ST | ||||||||
| Address2: | UNIVERSITY FAMILY HEALTH CENTER | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159721000 | ||||||||
| FaxNumber: | 8159721033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 05/02/2011 | ||||||||
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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 | 363LF0000X | 209001986 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209001986 | 01 | IL | IL STATE LICENSE | OTHER |