Provider Demographics
NPI:1073048120
Name:HEATHERLY, RHONDA RAYE (APN, FNP)
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:RAYE
Last Name:HEATHERLY
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S VICKSBURG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1930
Mailing Address - Country:US
Mailing Address - Phone:618-998-1900
Mailing Address - Fax:
Practice Address - Street 1:106 S VICKSBURG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1930
Practice Address - Country:US
Practice Address - Phone:618-998-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015818363LF0000X
IL209015818363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily