Provider Demographics
NPI:1295017663
Name:TACDERAS, DEANNA L (APN)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:L
Last Name:TACDERAS
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:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-529-0568
Practice Address - Street 1:317 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3671
Practice Address - Country:US
Practice Address - Phone:618-988-6171
Practice Address - Fax:618-988-6172
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009037363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily