Basic Information
Provider Information | |||||||||
NPI: | 1609018423 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLINGHAM | ||||||||
FirstName: | JANEL | ||||||||
MiddleName: | JENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 776351 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022725754 | ||||||||
FaxNumber: | 5022725339 | ||||||||
Practice Location | |||||||||
Address1: | 3999 DUTCHMANS LN | ||||||||
Address2: | SUITE 3C | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402074729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028996842 | ||||||||
FaxNumber: | 5028996920 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2009 | ||||||||
LastUpdateDate: | 12/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5089P | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3754966000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 7100097120 | 05 | KY |   | MEDICAID | 000000627881 | 01 | KY | ANTHEM NLPCC | OTHER | 108053 | 01 | KY | SIHO NLPCC | OTHER | 610978438T | 01 | KY | HUMANA | OTHER | 50026910 | 01 | KY | PASSPORT | OTHER |