Provider Demographics
NPI:1134493042
Name:VANNATTA, ANDREW (CO)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:VANNATTA
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 W EVERGREEN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1619
Mailing Address - Country:US
Mailing Address - Phone:217-342-3400
Mailing Address - Fax:217-342-3477
Practice Address - Street 1:1303 W EVERGREEN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1619
Practice Address - Country:US
Practice Address - Phone:217-342-3400
Practice Address - Fax:217-342-3477
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000290222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist