Provider Demographics
NPI:1073979555
Name:BALLANTINE, JILL (AGACNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BALLANTINE
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:BOEHMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:250 MERCY DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7320
Practice Address - Country:US
Practice Address - Phone:563-584-3226
Practice Address - Fax:563-584-3227
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH098201363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology