Basic Information
| Provider Information | |||||||||
| NPI: | 1659827418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIVIANO | ||||||||
| FirstName: | GAIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3613 BUCKLAND CT | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622267499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189773263 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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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 | 163W00000X | 041.385493 | IL | N | Nursing Service Providers | Registered Nurse | 163W00000X | 2012037887 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 209.01498 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209.01498 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.