Provider Demographics
NPI:1093069015
Name:VANNARATH, JOANNA L (APN)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:L
Last Name:VANNARATH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 W PARK ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2367
Mailing Address - Country:US
Mailing Address - Phone:217-337-2924
Mailing Address - Fax:217-337-2703
Practice Address - Street 1:1405 W PARK ST
Practice Address - Street 2:SUITE 303
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2367
Practice Address - Country:US
Practice Address - Phone:217-337-2924
Practice Address - Fax:217-337-2703
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009933363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily