Provider Demographics
NPI:1376881136
Name:GAZDA, DODIE (ANP-BC)
Entity Type:Individual
Prefix:
First Name:DODIE
Middle Name:
Last Name:GAZDA
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:DODIE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:PO BOX 19678
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9678
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4788
Practice Address - Street 1:315 W CARPENTER ST
Practice Address - Street 2:CLINIC B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4901
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-4788
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-010148363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid