Provider Demographics
NPI:1225570286
Name:WIBLE, CASSANDRA L (FNP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:L
Last Name:WIBLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:L
Other - Last Name:WIBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:783 CHANCELLOR DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3953
Mailing Address - Country:US
Mailing Address - Phone:618-558-7179
Mailing Address - Fax:
Practice Address - Street 1:21660 W FIELD PKWY
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:IL
Practice Address - Zip Code:60010-7265
Practice Address - Country:US
Practice Address - Phone:618-558-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277001899363L00000X
IL209015116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400342056Medicare PIN