Basic Information
| Provider Information | |||||||||
| NPI: | 1972892313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISTNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 NETWORK CENTRE DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624014632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173472707 | ||||||||
| FaxNumber: | 2173472827 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DIETERICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179255730 | ||||||||
| FaxNumber: | 2179255736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209008758 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 041359392 | 01 | IL | RN LICENSE | OTHER | 209008758 | 01 | IL | NURSE PRACTITIONER LICENSE | OTHER |