Basic Information
| Provider Information | |||||||||
| NPI: | 1902951841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALENTINE | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN/CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VALENTINE | ||||||||
| OtherFirstName: | SUE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN/CNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 544 W PERSHING RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178768370 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 544 W PERSHING RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
| FaxNumber: | 2178754680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209001529 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.