Basic Information
Provider Information | |||||||||
NPI: | 1982718938 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELTY | ||||||||
FirstName: | SHARON | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN MSNCS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRATHER | ||||||||
OtherFirstName: | SHARON | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 N EAST ST | ||||||||
Address2: | WEBER MEDICAL CLINIC LTD | ||||||||
City: | OLNEY | ||||||||
State: | IL | ||||||||
PostalCode: | 624502499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183955222 | ||||||||
FaxNumber: | 6183958552 | ||||||||
Practice Location | |||||||||
Address1: | 1200 N EAST ST | ||||||||
Address2: |   | ||||||||
City: | OLNEY | ||||||||
State: | IL | ||||||||
PostalCode: | 624502499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183955222 | ||||||||
FaxNumber: | 6183958552 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 363LA2200X |   | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 068527 | 01 | IL | HEALTH ALLIANCE | OTHER |