Provider Demographics
NPI:1033307780
Name:MORGAN, JUSTINE HOLLE (CFNP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:HOLLE
Last Name:MORGAN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:HOLLE
Other - Last Name:DAMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:PO BOX 19678
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9678
Mailing Address - Country:US
Mailing Address - Phone:217-545-7377
Mailing Address - Fax:217-545-7021
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 2W106
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-7377
Practice Address - Fax:217-545-7021
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-006692363LF0000X, 364SX0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0204XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology, Pediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid