Basic Information
| Provider Information | |||||||||
| NPI: | 1720165103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBURN | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178682812 | ||||||||
| FaxNumber: | 2172582216 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 DETTRO DR | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172383000 | ||||||||
| FaxNumber: | 2172383008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209006142 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 277000529 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P00678744 | 01 | IL | RAILROAD MEDICARE | OTHER | 036102377 1 | 05 | IL | MEDICAID | 041292879 | 05 | IL | MEDICAID | 1497762959 1 | 05 | IL | MEDICAID | 433990 | 01 | IL | MEDICARE GROUP | OTHER |