Provider Demographics
NPI:1417591330
Name:NEVERGALL, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:NEVERGALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1031
Mailing Address - Country:US
Mailing Address - Phone:618-283-0266
Mailing Address - Fax:
Practice Address - Street 1:1442 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1031
Practice Address - Country:US
Practice Address - Phone:618-283-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020293363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily