Provider Demographics
NPI:1417962937
Name:NANNIE, LISA (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NANNIE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:8914 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1410
Practice Address - Country:US
Practice Address - Phone:309-691-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001338363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL050884OtherHEALTH ALLIANCE
ILIL01W1OtherJOHN DEERE
IL472307OtherHEALTHLINK
IL7215059OtherBCBS PPO
IL472307OtherHEALTHLINK
IL7215059OtherBCBS PPO