Provider Demographics
NPI:1275570889
Name:NANNI, FREDERICA JO (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICA
Middle Name:JO
Last Name:NANNI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FREDERICA
Other - Middle Name:JO
Other - Last Name:FARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:4241 HWY 14 W
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-0155
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:618-724-4628
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110047Medicaid
ILCF3444OtherMEDICARE RAILROAD GROUP
IL370966854004Medicaid
IL207215Medicare PIN
IL640701Medicare Oscar/Certification
ILF641841Medicare UPIN
IL370966854004Medicaid