Provider Demographics
NPI:1235229535
Name:POLANIN, TERRYL A (FNP)
Entity Type:Individual
Prefix:
First Name:TERRYL
Middle Name:A
Last Name:POLANIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TERRYL
Other - Middle Name:A
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7669
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:2321 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-5613
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-681-4681
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041162013/209000866363L00000X
IL277-000264363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL993210Medicare ID - Type UnspecifiedINDIVIDUAL #
ILCA4079Medicare ID - Type UnspecifiedRR GROUP
IL809840Medicare ID - Type UnspecifiedGROUP #
ILK36856Medicare ID - Type UnspecifiedINDIVIDUAL #
S78394Medicare UPIN